exam 3

Which key feature does the nurse associate with a stage 2 pressure ulcer?

Presence of nonintact skin

A 10-year-old child is admitted to the hospital for surgery. The parents state that the child is mentally challenged and functions on the level of a 3-year-old. What should the nurse include in the child's preoperative teaching plan?

Providing explanations at a preschooler's level of understanding

A client is transferred to the postanesthesia care unit after undergoing a pyelolithotomy. The client's urinary output is 50 mL/hr. What should the nurse do?

Record the output as an expected finding.

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?

Removing the catheter within 24 hours

Sensory Information

• Preoperative holding area may be noisy • Drugs and cleaning solutions may be odorous • Operating room (OR) can be cold. Forced air warming devices may be used. Warm blankets are available • Talking may be heard but may be distorted because of masks. Ask questions if something is not understood • OR bed will be narrow. A safety strap will be applied over the thighs • Lights in the OR may be bright • Monitoring machines may be heard (e.g., beeping noises) when awake

The nurse is teaching a client about sleeping positions to follow to prevent pressure ulcers. Which statement made by the client indicates effective learning? Select all that apply. "I should use pressure-relieving pads." "I should place a rubber ring under the sacral area." "I should place pillows between two bony surfaces." "I should keep the head of the bed elevated above 30 degrees." "I should keep my heels off the bed surface using a bed pillow under the ankles."

"I should use pressure-relieving pads." "I should place pillows between two bony surfaces." "I should keep my heels off the bed surface using a bed pillow under the ankles."

Common Preoperative Diagnostic Studies

-ABGs,pulse oximetry: Respiratory and metabolic function, oxygenation status -Blood glucose: Metabolic status, diabetes -Blood urea nitrogen, creatinine: Renal function -Chest x-ray:Lung disorders, cardiac enlargement, heart failure -CBC: RBCs, Hgb, Hct, WBCs: Anemia, immune status, infection -Electrocardiogram Heart disease, dysrhythmias -Electrolytes: Metabolic status, renal function, diuretic side effects -hCG: Pregnancy status -Liver function tests: Liver status -PT, PTT, INR, platelet count: Coagulation status Pulmonary function studies: Pulmonary status -Serum albumin: Nutritional status -Type and crossmatch: Blood available for replacement (elective surgery patients may have own blood available) -Urinalysis:123 Renal status, hydration, urinary tract infection

Hydrocoloid dressing

-Gelatin, pectin, or carboxymethylcellulose bonded to a film or sheet. Produce a flat occlusive dressing that forms a gel on wound surface. Occlusion does not interfere with wound healing. Support autolytic debridement and prevent secondary infections -Wounds with light to moderate drainage

gauze

-Made of woven or nonwoven material. Absorb exudates. Most often combined with another kind of dressing -Can be used on almost any kind of wound. Cleansing, packing, and covering a variety of wounds

mechanical debridement

-Methods: • Wet-to-dry dressings, in which open-mesh gauze is moistened with normal saline, lightly packed into wound surface, and outer layer allowed to dry. Wound debris adheres to dressing and then dressing is removed • Wound irrigation. Make certain bacteria are not accidentally driven into wound with high irrigation pressure • Noncontact low-frequency ultrasound and ultrasonic mist

In the postanesthesia care unit a client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care?

-Monitoring of respiratory rate hourly

A nurse is teaching a preoperative client about postoperative breathing exercises. Which information should the nurse include? Select all that apply. Take short, frequent breaths Exhale with the mouth open wide Perform the exercises twice a day Place a hand on the abdomen while feeling it rise Hold the breath for several seconds at the height of inspiration

-Place a hand on the abdomen while feeling it rise -Hold the breath for several seconds at the height of inspiration

Debriefing

-Pt. confirmed identity,site,procedure, consent -site marked -anesthesia safe completed -pulse oximetry on patient and functioning -does pt. have known allergy? -difficulty airway or aspiration? -risk of >5000 ml blood loss or 7 ml/kg in children -

A client underwent surgery and developed a wound without tissue loss. While caring for the client, the nurse detects abscess formation. Which assessments made by the nurse support the observation? Select all that apply. -Necrosis of skin edges -Swelling of the incision line -Purulent drainage from the incision site -Erythema of the incision line of more than 1 cm -Localized fluctuance beneath the wound when palpated

-Purulent drainage from the incision site -Localized fluctuance beneath the wound when palpated --Swelling of the incision line

Non-adherent dressing

-Woven or nonwoven dressings. May be impregnated with saline, petrolatum, or antimicrobials. Minimally absorbent -Minor wounds or as a second dressing

prevention:nutrition

-caloric intake elevated to 30-35 cal/kg/day or -1.25- 1.50 g protein/kg/day

Timeout

-confirm all team members have introduce themselves by name and role - ACP and nurse verbally confirm patient, site, procedure -anticipated critical events: A. surgeon reviews what are the critical or unexpected steps, operative duration, anticipated blood loss. B. ACP reviews are there any patient specific concerns? C. nursing team reviews has sterility including indicator results been confirmed?, are ther equipment issues or any concerns? - has antibiotic prophylaxis given in the last 60 mins?

the braden scale

-consists of six subscales based on common causes of dermal ulcers: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. -Adults scoring less than 18 of 23 possible points on the Braden scale are considered at risk for dermal ulcers. -The scale is often completed as part of a health care facility admission assessment and periodic reassessment. Persons found to be at higher risk should have more intensive preventive measures instituted. Those at risk in home settings can be taught to assess their own skin with the assistance of family members or caregivers. -Prevention interventions include minimizing or eliminating friction and shear (e.g., sliding on sheets), minimizing pressure through frequent repositioning and use of pressure-relieving devices, managing moisture on skin surfaces, and maintaining adequate nutrition and hydration.

circulating nurse

-coordinator of intra-operative activities -who ensures the proper equipment and machine in the operating room where it needs to be. -who wears clean scrub attire -who counts the dressing

antimicrobial dressings

-deliver antibacterial agents. -ex. silver -change 2-3x per day

Midazolam, a benzodiazepine

-depresses subcortical levels in the central nervous system and acts on the limbic system and reticular formation; it reduces anxiety and induces sedation.

Spinal anesthesia

-involves the injection of a local anesthetic into the cerebrospinal fluid in the subarachnoid space, usually below the level of L2 -used for procedures involving the extremities (e.g., joint replacements) and lower gastrointestinal, prostate, and gynecologic surgeries.

Hyperbaric O2 therapy (HBOT)

-is the delivery of O2 at increased atmospheric pressures. It can be given topically by creating a chamber around the injured limb. It also can be given systemically with the patient in an enclosed chamber, receiving 100% O2 at 1.5 to 3 times the normal atmospheric pressure. -

risk factor for skin breakdown

-limited immobility -poor nutrition -limited activity -poor sensory perception -poor perfusion and oxygenation -moisture -friction and shear issue

Assess the Wound

-location, size, shape, and color as well as the color, odor, and consistency of any drainage or exudate. -Redness of the surrounding tissue, foul odor, or purulent drainage may indicate wound infection.

ACP

-managing IV FLUID during surgery -who manage pain relief in the operating room -who maintains pt's airway -who runs the medical management of the patient during sx. (glucose order, -who wears clean scrub attire -who ask about pt. allergies -who runs the code(CPR)

surgeon

-therapeutic goal of surgery -obtain the consent of patient surgery -WHO gets signature on the consent form -who gets the decision what pain med after surgery -who tells the pt. the failure rate of sx -who tells the pt. the mortality rate of sx. -who tells the patient other treatments other than surgery -who tells the pt. risks of not having sx. -who tells the medical diagnosis that requires sx. -who wears sterile attire

autolytic debridement

-using body's enzymes to break down tissue -Moisture-retentive semiocclusive or occlusive dressings (e.g., hydrocolloids, transparent films, hydrogels) (Table 11.9) that soften dry eschar by autolysis • -Must assess area around wound for maceration

surgical tech/scrub nurse

-who ensures the proper equipment and machine in the operating room where it needs to be -who wears sterile attire

surgical debridement

-• Quick method of debridement to prevent, control, or remove infection -• Used when large amounts of nonviable tissue are present -• Prepares wound bed for healing, skin grafting, or flaps

The expected serum creatinine range

0.7 to 1.4 mg /dL (62 to 124 mcmol/L)

Wound culture procedure

1. before the procedure, manage pan issues as necessary 2. if possible obtain the specimen before the patient starts antimicrobial therapy 3. gather equipment: -clean gloves -30-35ml syringe with 19g plastic angiocath or 10 ml syringe prefilled with sterile .9%NS -sterile gauze pads -culture swab with sterile swab container -wound dressing 4.after performing hand hygiene and putting on clean gloves, irrigate the wound with sterile .9% NS and wipe gently with a gauze pad. 5. moisten the swab with sterile .9%NS (a moist swab provides more accurate data than a dry swab). 6. identify a small area (1 cm2) of clean viable tissue and rotate the swab on it, avoiding any necrotic tissue. Applying pressure, try to express as much as nonpurulent wound fluid as possible. A wound culture must be taken from clean tissue because pus or necrotic tissue will not provide an accurate profile of the microflora contained within the tissue. 7. redress the wound and perform hand hygiene 8. assess the patient and ensure that any wound pain has been managed. 9. complete the lab slip and/or electronic document, including wound site, time the specimen was collected, and any antimicrobials the patient is receiving. 10. send the specimen to the lab immediately(within 1 hour) to keep the specimen stable.

A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets

2

The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan?

Administering general anesthetic to the client

A client with a history of recurrent cholecystitis is scheduled for an abdominal cholecystectomy. What should the nurse specifically emphasize when planning preoperative teaching for this client?

Coughing and deep breathing

A client is hospitalized with pressure ulcers. Which task could be delegated to an unlicensed nursing professional (UNP)? Select all that apply: Empty wound drainage containers. Report changes in wound appearance. Apply prescribed dressings and medications. Assess and record data about wound appearance. Choose dressings and therapies for wound treatment

Empty wound drainage containers. Report changes in wound appearance.

stage 3

Full-thickness skin loss full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mcmol/L). What should the nurse do first in response to this laboratory result?

Obtain current blood test results.

Common Conditions Associated with Dermal Ulcer Development

Spinal cord injury Stroke Traumatic brain injury Trauma Skeletal fractures Neuromuscular disorders Rheumatoid arthritis Parkinson's disease Multiple sclerosis Alzheimer's disease Heart failure Peripheral arterial disease Chronic obstructive pulmonary disease Diabetes (type 1 and type 2)

The primary healthcare provider treats a client with a pressure ulcer. While assessing the client, the nurse identifies exposed bone and tendons. Which stage does the nurse document for this pressure ulcer?

Stage IV

A nurse is evaluating a client's understanding regarding postoperative concerns after a mastectomy. Which unanticipated development near and around the incision noted by the client should be reported to her primary healthcare provider?

Swelling with erythema

A client with a long history of asthma is scheduled for surgery. Which information should be included in preoperative teaching?

There is an increased risk of respiratory tract infections.

Vacuum-assisted closure systems

are special dressings for complex wounds attached to a device that maintains negative pressure at the wound surface, aiding in removal of large amounts of exudates.

Nonadherent dressings

are useful when the wound drainage is slight and may dry between dressing changes, causing the dressing to stick to the fragile wound surface and then disrupt the wound during dressing removal.

tissue biopsy

arious types of biopsies—such as punch, incision, excision, and shave—are conducted for pathologic evaluation of tissue when skin lesions are suspected to be malignant. The type and depth of biopsy are based on the lesion and the location.

Primary intention wound healing

occurs when wound margins are well approximated, as in a sutured surgical incision or a simple laceration, and takes place more rapidly than the other types of healing.

Process Information Information About General Flow of Surgery

• Admission area • Preoperative holding area, OR, and postanesthesia care unit (PACU) • Caregivers can usually stay in preoperative holding area until surgery • Caregivers will be able to see patient after discharge from the PACU or possibly in PACU once the patient is awake • Identification of any technology that may be present on awakening, such as monitors, central lines, intermittent pneumatic compression devices

Where Caregivers Can Wait During Surgery

• Encourage caregivers to ask questions and express any concerns • OR staff will update caregivers during surgery and when surgery is over • Surgeon will usually talk with caregivers after surgery

Regional anesthesia

• Loss of sensation to a region of body without loss of consciousness • Involves blocking a specific nerve or group of nerves by administering a local anesthetic • Includes spinal, caudal, and epidural anesthesia and IV and peripheral nerve blocks (e.g., interscalene, axillary, infra-/supra-clavicular, popliteal, femoral, sciatic)

General anesthesia

• Loss of sensation with loss of consciousness • Combination of hypnosis, analgesia, and amnesia • Usually involves use of inhalation agents • Skeletal muscle relaxation • Elimination of coughing, gagging, vomiting, and sympathetic nervous system responsiveness • Requires advanced airway management

Local anesthesia

• Loss of sensation without loss of consciousness • Induced topically or via infiltration, intracutaneously, or subcutaneously • Topical applications may be aerosolized or nebulized

benzo nsg intervention

• Monitor level of consciousness. Assess for respiratory depression, hypotension, and tachycardia. • Reverse severe benzodiazepine-induced respiratory depression with flumazenil (Romazicon).

Moderate sedation/analgesia (formerly called conscious sedation)

• Sedative, anxiolytic, and/or analgesic drugs used • Does not include use of inhalation agents • Patient responsive and breathes without assistance • Not expected to induce level of sedation that would impair patients' ability to protect their airway • Most often used for minor therapeutic procedures (e.g., fracture realignment in the emergency department)

Procedural Information

• What to bring and what type of clothing to wear to the surgery center • Any changes in time of surgery • Fluid and food restrictions • Physical preparation needed (e.g., shower, bowel, or skin preparation) • Purpose of frequent vital signs assessment • Pain control and other comfort measures • Why turning, deep breathing, and coughing after surgery are important. Do practice sessions • Insertion of IV lines • Procedure for anesthesia administration • Surgical site may be marked with indelible ink or marker

What is the etiology for the development of pressure ulcers in an 80-year-old client?

Decreased subcutaneous fat

Stage 4

Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.

Low urine output (800 to 1500 mL) in the first 24 hours

-expected regardless of fluid intake. Causes include increased aldosterone and ADH secretion resulting from the stress of surgery; fluid restriction before surgery; and fluid loss through surgery, drainage, and diaphoresis.

Pre-op nurse

-fill out the pre-op checklist -WHO gets a signature on the consent form-who ask about allergies -pain assessment technique -performing IV access -telling the patient the process of flow (floor, preop, PACU, floor -assess the patient on their emotional state -assess the health history and review of systems -check results of the pre-op labs -who wears clean scrub attire -who assess the physical and emotional status -who tells the patient what they see feel and hear

epidural block

-involves injection of a local anesthetic into the epidural space via a thoracic or lumbar approach (Fig. 18.6, B). The anesthetic agent does not enter the cerebrospinal fluid but binds to nerve roots as they enter and exit the spinal cord. -in obstetrics, vascular procedures involving the lower extremities, lung resections, and renal and midabdominal surgeries.

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action?

Turn and reposition the client every 2 hours.

Occlusive and semiocclusive dressings

are used for clean wounds that have minimal drainage but need to be protected from environmental pathogens, such as a central intravenous catheter puncture site.

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers?

inspecting the skin daily

tertiary closure. (delayed primary closure).

is used when a wound must stay open until infection or wound contamination is resolved; later, the clean wound is sutured to facilitate continued healing.

Up to 12 hr Hypothermia: ≤96.8°F (36°C)

possible cause: Effects of anesthesia, body heat loss during surgical procedure

After first 48 hr (postoperative day 3 and later) Elevation greater than 100°F (37.8°C)

possible cause: Infection (e.g., wound, urinary, respiratory)

First 48 hr (postop day 1 and 2) Mild elevation: lesser than 100.4°F (38°C)

possible cause: Inflammatory response to surgical stress

First 48 hr (postop day 1 and 2) Moderate elevation: greater than 100.4°F (38°C)

possible cause: Lung congestion, dehydration

Tertiary intention wound healing

processes occur when a wound is sutured closed much later, resulting in more scarring than that which occurs for wounds closed with primary intention.

secondary intention wound healing

processes occur when wounds such as ulcerations have distant edges and granulation tissue gradually fills the gap to close the wound.

assess dermal wound ulcer

size and depth, as well as for level of tissue injury

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer?

the sacrum, bears the most pressure because it is the focal point of the weight of the body when in the low Fowler position; also, shearing forces may cause local tissue trauma.

Opioid nsg. intervention

• Assess respiratory rate and rhythm, monitor pulse oximetry, protect airway in anticipation of vomiting. • Use standing orders for antipruritics and antiemetics. • Reverse opioid-induced respiratory depression with naloxone. If used, reversal of analgesic effects also occurs.

Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse best reinforce the preoperative teaching?

"A pillow under the knees can result in clot formation because it slows blood flow.

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?

"Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale."

A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching?

"I should not worry about what the client eats."

The nurse instructs self-management tips on the safety and quality care for skin cleaning to a client with a pressure ulcer. Which statement of the client shows ineffective learning?

"I will apply powders and talc on the perineum."

While performing preoperative teaching a nurse explores a young adolescent's concern about changes in appearance after surgery to correct scoliosis. What is the most appropriate statement by the nurse?

"You're concerned about how you'll look after surgery."

Hydrogel dressing

-Available in gels, gel-covered gauze, or sheets. Give moisture to a dry wound and maintain a moist environment. Can rehydrate wound tissue. Debridement (autolytic) because of moisturizing effects. Require a secondary dressing -Dry wounds. Wounds with minimal drainage. Necrotic wounds. May have a cooling effect to help decrease pain

Alginate

-Derived from processed seaweed or kelp. Form a nonstick gel on contact with draining wound. Highly absorbent. Easy to use over irregular-shaped wounds. Require a secondary dressing -Wounds with moderate to heavy exudates (e.g., pressure injuries, infected wounds)

When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. Which is the priority nursing action?

Ask the client which herbs have been taken

wound culture

Cultures identify the organisms causing infection. Because some bacteria are present on healthy skin, normal skin flora may be identified in wound cultures along with any pathogenic bacteria.

Which priority interventions should be followed by the nurse when caring for a client with malignant hyperthermia? Select all that apply. Administer 100% oxygen. Intubate with an endotracheal tube. Monitor the core body temperature. Stop all inhalation anesthetic agents. Insert an indwelling urinary catheter

Administer 100% oxygen. Intubate with an endotracheal tube. Stop all inhalation anesthetic agents.

A client has a total hysterectomy with bilateral salpingo-oophorectomy for cancer of the ovary. In addition to encouraging ambulation, what exercise should the nurse instruct the client to perform to help prevent postoperative deep vein thrombosis (DVT)?

Ankle pumping is the most effective to prevent DVT. It requires contraction and relaxation of the tibialis anterior muscles, the gastrocnemius muscles, and the soleus muscles as the client alternates dorsal and plantar flexion. These movements cause contraction of the skeletal muscles, which exerts pressure on the veins to facilitate venous return

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply. Age Anorexia Hemiplegia History of diabetes Urinary incontinence

Anorexia Hemiplegia History of diabetes Urinary incontinence

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention?

Attempt to identify the client's concerns.

A healthcare team is caring for a postsurgical client who underwent knee surgery. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply. Changing the dressing Ambulating the client Administration of oral analgesics Reinforcing leg exercise instructions Administering intravenous antibiotics

Changing the dressing Administration of oral analgesics Reinforcing leg exercise instructions

A 9-year-old child is returned to the postanesthesia care unit after surgery to correct a compound fracture of the humerus. An intravenous (IV) infusion pump is in place, delivering D5% 0.45% NS at a rate of 70 mL/hr. What action will the postanesthesia care nurse implement?

Continue the current solution and flow rate

A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse?

Dyspnea

A client with a history of endometriosis has abdominal surgery to remove abdominal adhesions. What should this client's postoperative plan of care include?

Encouraging the client to ambulate in the hallway

A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient care analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next?

Give naloxone intravenous push med (IVP) per protocol.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers?

Incontinence and inability to move independently

After a prostatectomy, a client's plan of care will include the prevention of postoperative deep vein thrombosis. Which nursing goal will best achieve prevention?

Increase velocity of the venous return

A healthcare provider informs a client that midazolam will be administered preoperatively. Later, the client asks the nurse why this medication is given. What primary reason should the nurse consider when formulating a response?

Induces sedation

Which practice would be suitable in the prevention of a pressure ulcer?

Keeping the client's skin directly off plastic surfaces

Stage 1

Non-blanchable erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

A female client is scheduled for a hysterectomy. While discussing the preoperative preparations, the nurse determines that the client's understanding of the surgery is inadequate. What is the next nursing intervention?

Notifying the surgeon that the client needs more information

A client is admitted to the hospital for cranial surgery. What does the nurse include in the preoperative plan of care?

Obtaining the client's consent for shaving the head

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding?

Oliguria

Stage 2

Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister.

A nurse reviews the preoperative instructions for a 3.5-year-old child who is to undergo follow-up cleft palate surgery. Which instruction should the nurse question? Nothing by mouth after midnight. Start IV of D5% 0.45% NS at 6 AM. Tap water enema until clear this PM. Draw blood for HgB and Hct this PM

Tap water enema until clear this PM.

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer?

The client should have been turned regularly

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus?

Unilateral chest pain Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or by pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, because of reduced oxygenation and possible shock.

moist dressings

Used to maintain a slightly damp environment to promote tissue repair

A nurse is preparing to administer preoperative medication to a client scheduled for incision and drainage of a wound abscess. Which action is essential before the nurse administers the medication?

Verify the consent.

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

With the help of another staff member, use a drawsheet when lifting the client in bed.

Intrathecal morphine

can depress respiratory function depending on the level it reaches within the spinal column; hourly assessments during the first 12 to 24 hours will allow for early intervention with an antidote if respiratory depression needs to be corrected. Bradycardia and hypotension occur.

maturation phase of wound healing

collagen fiber remodeling and scar contraction may continue for months or years

suspected deep tissue injury

depth unknown A purple or a maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

Inflammatory phase of wound healing

lasts 3-5 days while blood clots form at the site of injury and platelets release growth factors to begin the healing process. A matrix of cells and debris forms at the site and is later removed by macrophages.

Granulation phase of wound healing

new vessels and collagen structures are formed, resulting in a very vascular pink wound. White blood cells continue to remove debris while epithelium begins to grow from the edges toward the center of the wound.

The registered nurse (RN) is caring for a client who underwent surgery for a pituitary tumor. Which task can be delegated to unlicensed nursing personnel (UNP)?

vital signs can be monitored by the (UAP) if the client has stable vital signs.

Post Briefing

nurse verbally confirms with the team: -the name of the procedure recorded -that instrument, sponge and needle counts are correct -how the specimen labeled -whether there any equipment problems need to address -surgeon, ACP, and nurse review the key concerns for recovery and management of this patient.

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply. "I will elevate the head of the client's bed to 30 degrees." "I will instruct the client to take baths in lukewarm water." "I will advise the client to apply talc directly to the perineum." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." "I will teach the client to refrain from eating a high-protein and calorie diet."

"I will elevate the head of the client's bed to 30 degrees." "I will instruct the client to take baths in lukewarm water." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day."

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers?

Frequent repositioning of client

Unstageable/Unclassified Pressure Ulcer

Full thickness skin or tissue loss—depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Dry dressings

are used to absorb excessive exudates, whereas moist dressings

hydrocolloid, hydrogel, alginate dressings

are used to absorb exudates while maintaining a therapeutically moist wound surface to promote healing.