Unit 5 PrepU

dark-amber

A client has been n.p.o. after midnight for surgery. It is 11 a.m. and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color?

• Obesity • Excessive perspiration • Low BMI

A nurse assessing the skin of clients knows that the following are health states that may predispose clients to skin alterations. Select all that apply.

Alginate

A nurse is caring for a client who has a 6-cm × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which dressing does the nurse anticipate is best to be ordered by the primary care provider?

Different types of dressing

Alginates are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue. Hydrogels are used with dry wounds or wounds with minimal drainage. Hydrocolloids are used with light to moderate drainage in wounds with necrosis or slough. Transparent dressings are used with wounds having minimal drainage, small size, and partial thickness

Phases of wound healing

Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin with other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and to release growth factors. The proliferation phase is the regenerative phase in which granulation tissue is formed. The maturation phase involves collagen remodeling.

"I make sure to limit how much I drink so that I don't have accidents."

Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?

Types of incontinence

Stress incontinence occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure. This commonly occurs during coughing, sneezing, laughing, or other physical activities. Transient incontinence appears suddenly and lasts for 6 months or less. It is usually caused by treatable factors, such as confusion secondary to acute illness, infection, and as a result of medical treatment (e.g., use of diuretics, IV fluid administration). Total incontinence is a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation. Urination cannot be controlled due to an anatomic abnormality.

"You are experiencing stress incontinence. Do you know how to do Kegel exercises?"

The nurse is assessing a female client who states that she notices an involuntary loss of urine following a coughing episode. What would be the nurse's best reply?

Hemostasis

The nurse is caring for a client in the emergency department who cut herself 15 minutes ago while preparing dinner at her home. The nurse understands the client's wound is in which phase of wound healing?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse is caring for a client who has a pressure ulcer on his back. What nursing intervention would the nurse perform?

Hemostasis Inflammatory Proliferation Maturation

The nurse is caring for a client who has a stage IV pressure ulcer. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order.

The catheter can be connected to a smaller leg bag for ambulation.

The nurse is providing education to a client who is being discharged to home with an indwelling urinary catheter in place. What information is important for the nurse to discuss with the client?

"Do you experience incontinence?"

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

Corticosteroids

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

• It is responsible for producing the proteins collagen and elastin. • It is the thickest skin layer.

What is true about the dermis? Select all that apply.

off-load pressure from the heel

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Catheterized clients should drain a minimum of 30 mL of urine per hour

Which is true regarding the normal urination?

Reddened perineal skin

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which of the following would the nurse document as an abnormal finding?