Unit 1 - 292

a nurse identifies a pressure ulcer after a client had a ling, extensive recovery following a surgical procedure. when completing an incident report about the pressure ulcer, the nurse should take which if the following actions? a. document with the nurse believes was the cause of ulcer development b. include any relevant statements the client made about the ulcer c. document in the clients medical record that she completed an incident report d. question the charge nurse about care deficits that night have contributed to the ulcers development

include any relevant statements the client made about the ulcer

a nurse is providing hygiene care for a client who is immobile. which of the following actions should the nurse take? (SATA) a. check for personal items when changing the bed linens b. place a clean gown on the strongest arm first c. keep the bath water temp between 43.3 C (110 F) and 46.1 C (115 F) d. shave the clients hair in the direction of the hair growth e. wash the clients extremities from proximal to distal

-check for personal items when changing the bed linens -keep the bath water temp between 43.3 C (110 F) and 46.1 C (115 F) -shave the clients hair in the direction of the hair growth

a nurse is caring for an older adult client who is at risk for skin breakdown. what should the nurse do to maintain integrity of the clients skin? a. repo every 3 hrs b. massage bony prominences to promote circulation c. provide the client with a diet high in protein d. apply cornstarch to keep the skin dry

provide the client with a diet high in protein

a nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. which if the following interventions should the nurse include in the plan? a. apply a heat lamp twice a day b. repo at least every 2 hr c. clean the wound with hydrogen peroxide solution d. massage reddened areas with dressing changes

repo at least every 2 hr

a nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include in the info which of the following alterations for wound healing by secondary intention? (SATA) a. stage 3 pressure injury b. sutured surgical incision c. casted bone fracture d. laceration sealed with adhesive e. open burn area

stage 3 pressure injury open burn area

a nurse is caring for a client who is receiving heat applications using an aquathermia pad. which if the following actions should the nurse take when applying the pad? a. set the pad temp to 42.2 C (108 F) b. stop the treatment if the clients skin becomes red c. leave the pad in place for at least 40 minutes d. use safety pins to keep the pad in place

stop the treatment if the clients skin becomes red

a nurse is caring for a client who has urinary incontinence. which of the following actions should the nurse implement to prevent the development of skin breakdown a. apply a moisture barrier cream to the client's skin b. clean the clients skin and perineum with how water after every episode of incontinence c. check the clients skin every 8 hrs for signs of breakdown d. request a prescription for the insertion of an indwelling catheter

apply a moisture barrier cream to the client's skin

a nurse is caring for a client who is 2 days postop following an appendectomy and has type 1 diabetes, their Hgb is 12 g/dL and BMI is 17.1. The incision os approximated and free of redness, with scant serous draining in the dressing, the nurse should recognize that the client has which of the following risk factors for impaired wound healing. (SATA) a. extremes in age b. chronic illness c. low hemoglobin d. malnutrition e. poor wound care

chronic illness low hemoglobin malnutrition

a nurse is providing unit care for a client. which of the following actions should the nurse take? a. clean under the nail with an orange stick b. file the nails in a rounded shape c. push the cuticles back with a metal nail file d. trim the nails at the lateral corners

clean under the nail with an orange stick

a nurse is collecting data from a client who is 5 days postop following abdominal surgery. the surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. which of the following finding should the nurse expect? (SATA) a. increase in incisional pain b. fever and chills c. reddened wound edges d. increase in serosanguineous drainage e. decrease in thirst

increase in incisional pain fever and chills reddened wound edges

a nurse working un an emergency room is assessing a client who has a leg wound. the nurse notes a full thickness wound with jagged edges and muscle tissue visible. the nurse should document this as which of the following types of wounds? a. abrasion b. contusion c. laceration d. puncture

laceration

a nurse is assessing a client who has a pressure ulcer. the nurse should recognize which of the following findings as a manifestation of a stage 3 ulcer? a. exposed bone b. blood filled blisters c. partial-thickness skin loss d. necrotic subcutaneous tissue

necrotic subcutaneous tissue

a nurse is planning care for an older adult client who is at risk for developing pressure ulcers. which of the following interventions should the nurse use to help maintain the integrity of the clients skin? a. use a transfer device to lift the client up in bed b. apply cornstarch to keep sensitive skin areas dry c. massage the skin over the clients bony prominences d. elevate the head of the bed no more than 45 degrees

use a transfer device to lift the client up in bed