Wound Care Pass Point + Oxygenation

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care?

Place the client on a pressure redistribution bed.

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?

The dressing should keep the wound moist.

The nurse is performing wound care on a client with an open fracture. What is the nurse's priority action to clean the wound?

Irrigate the wound with normal saline.

The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?

Apply a hydrocolloidal dressing.

A nurse is providing wound care to a client 1 day after an appendectomy. A drain was inserted into the incisional site during surgery. What should the nurse do to provide wound care?

Clean the area around the drain, moving away from the drain.

Which nutritional deficiency may delay wound healing?

lack of vitamin C

The nurse is bathing a client and discovers a pressure injury on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first?

Position the client off of the injury.

An infant requires tracheal suctioning after the nurse assesses airway congestion. Which is the priority initial action when performing the procedure?

oxygenation prior to the procedure

When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure injuries, the nurse should emphasize that most tissue injuries related to shearing can be prevented by which action?

proper positioning and moving of the client

The nurse is assessing a hospitalized older adult client for the presence of pressure injuries. The nurse notes that the client has a 1 × 1-inch (3 × 3-cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record?

stage II pressure injury

A nurse is reviewing the medications used by a client who has chronic bronchitis and a history of high blood pressure and prostate enlargement. The nurse should verify that the client understands that which medications should be avoided because of the risks they pose?

-guaifenesin with dextromethorphan liquid (cough suppressant) -generic pseudoephedrine tablets

While caring for a client who's immobile, a nurse documents this information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?

Risk for impaired skin integrity related to immobility

A client is admitted to the emergency department with crushing chest injuries sustained in a car crash. The nurse is assessing the client's respiratory status. Which sign indicates a possible complication that the nurse should report to the health care provider immediately?

absent breath sounds on the affected side

When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing?

adequate circulatory status

The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation?

arterial blood gases

A client tells the nurse he is experiencing dyspnea. Which position will the nurse place the client in?

high Fowler's position

A nurse is assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action?

increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis

The nurse is assessing a client with pneumonia. Which change in the client's mental status is concerning at this time?

irritability

The nurse is caring for an immobile client. Which intervention should the nurse prioritize?

keeping the skin clean and dry with gentle soap

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?

lean meats and low-fat milk

To prevent oral complications when using a fluticasone metered-dose inhaler, a nurse should instruct the client to do what?

-Rinse out the mouth after using the inhaler. -Keep the mouth piece from becoming contaminated. -Add a spacer to the metered dose inhaler.

Which statement would be appropriate for a nurse documenting a stage 1 pressure injury found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony

A client says, "I hate the idea of being an invalid after they cut off my leg." Which response by the nurse would be the most therapeutic?

"Tell me more about how you're feeling."

A nurse is instructing a patient with asthma on the use of an inhaler with a spacer. The patient asks what the purpose of the spacer is. The nurse's best response is:

"The spacer traps medicine from the inhaler, then breaks up and slows down the medication particles, so you get more medication."

Which is the best nursing response to make when a client asks why there are small lumps under the suture line of the incision three weeks after abdominal surgery?

"Those lumps are caused by new tissue growing at different rates."

The nurse is offering further education to a client about the management of COPD. Which outcomes would indicate the teaching has been effective?

-The client demonstrates pursed-lip breathing and coughing exercises. -The client maintains smoking cessation. -The client continues to smoke four cigarettes a day.

The community health nurse is working with a client who has limited mobility. Which interventions would the nurse implement for primary prevention of skin breakdown?

-encouragement of the client to walk around the home three times a day -education of the client on turning frequently in the bed if lying down -instruction on the application of lotion for dry skin on extremities

The nurse assesses a client with a fever and a draining arm wound. The healthcare provider suspects a methicillin-resistant Staphylococcus aureus (MRSA) infection and issues orders. What health care provider order will the nurse implement first?

Cleanse the area around the wound, and obtain a culture.

When caring for a patient with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?

Using normal saline solution to clean the ulcer and applying a protective dressing as

When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers?

a client who has a decreased serum albumin level