josephine morrow vsim

the nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time?

ask the pt to press the call bell to summon a co-worker to obtain another dressing

the nurse is caring for a pt with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the plan of care for this pt? (SATA)

assist with ROM exercise to lower extremity, perform neurovascular checks to looks for changes, monitor pt skin for breakdown, provide meticulous skin care

the nurse is providing ducationto ms.morrow and her daughter on nutrition. what is the best dietary choic eto promote wound healing?

baked chicken (highest in protein)

the nurse is assessing a pt admitted with a venous stasis ulcer on the right lower extremity. what should the nurse expect to find when assessing the leg?

dark discoloration of the skin surrounding the wound site

the nurse assesses a wound and documents it as stage 3. what did the nurse observe when the wound was assessed?

full thickness tissue loss, possibly with visible subcutaneous fat.

the nurse is completing an admission assessment on a pt admitted for impaired skin integrity. which questions would be appropriate for the nurse to ask the patient?

have you noticed any swelling on your feet, ankles or fingers?, do some area of your skin seem warmer or colder than others?, have you used pads or special pants because you cannot control your urine?, do you have any sores on your body?

the nurse is conducting a skin assessment using braden scale. how would the nurse interpret the score 12?

high risk

the nurse is preparing to irrigate a wound. which statement, if made by the nurse, indicates an understanding of the procedure?

i will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound

the nurse is preparing to irrigate a pt's wound. upon assessment, the wound appears to be healing and the wound bed is beefy red. which solution should the nurse select for this procedure/

normal saline

the nurse is completing an admission assessment on a pt admitted for an infected non-healing wound.which factors in the pt history may contribute to this condition?

poor hygiene, obesity, DM, poor circulation

The nurse is reviewing a pt's lab results. which lab test most accurately represent nutritional status?

pre-albumin ( has a shorter half life and is a more sensitive measure of current nutritional status)

the nurse removes a dressing and assesses yellow foul smelling drainage. How would the nurse document this finding?

purulent

the nurse is providing education to Ms. Morrow and her daughter on management of venous stasis in the lower extremity. What should be appropriate for the nurse to include in the teaching session?

put an anti embolism stocking as soon as you wake up in the morning and wear them all day

the nurse is irrigating a pt wound when the pt complains of pain. what is the appropriate action by the nurse?

stop the procedure and administer the ordered analgesic

the nurse has received an order to apply a hydrocolloid dressing to ms. morrow's right lower extremity. which statement if made by the nurse would indicate need for further teaching?

the dressing will need to be held in place with a surgical tape

Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's wound. What is the appropriate response by the nurse?

the procedure helps remove drainage and debris from the wound

the nurse is performing an assessment of Ms.Morrow's wound. what should be included in the documentation?

tunneling, odor, location, drainage

the nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history?

when did the edema start?, can you describe the edema?, what were you doing before you noticed the edema?, do you have any recent hx of surgery or illness?, what are your usual ADL?, do you stand a lot?, what meds do you take?, do you have heart disease or blood vessel disease?