1128 PrepU Tissue

A nurse is viewing a list of clients. Which clients would the nurse anticipate to be at risk for skin breakdown? Select all that apply.

-a 60-year old client post-cardiac catheterization -a 30-year old client with a fractured L3-L4 -an 80-year old client with incontinence of urine -a 50-year old client with a newly diagnosed stroke

Which nursing intervention can help a client maintain healthy skin?

Keeping the client well hydrated

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?

D

Which is a priority nursing assessment of a reddened heel in a bed-ridden client?

Test for blanching to the affected area.

Which sentence correctly describes the prone position?

The body is facedown.

The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse document this drainage?

clear, watery, yellow-tinged drainage

A hospitalized patient has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition?

poor wound healing, apathy, edema The stress of illness, surgery, or prolonged periods of time on simple intravenous therapy without oral intake places hospitalized clients at risk for developing protein-calorie malnutrition. This can result in weakness, poor wound healing, mental apathy, and edema.

A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action?

small amount of creamy yellow drainage

The nurse is caring for a client who has paraplegia following a hunting accident. The nurse knows to assess regularly for the development of pressure ulcers on this client. What rationale should the nurse cite for this nursing action?

The risk for pressure ulcers is directly related to the duration of immobility. If pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results.