NR 224- Week 3 EDAPTS- Hygiene and Tissue Integrity

Client has altered cognition resulting from dementia, psychological disorders, or temporary delirium. Client unable to verbalize skin care needs Predisposition to impaired tissue synthesis Client unable to feel skin injury Moisture is medium for bacterial growth and causes local skin irritation

Client unable to verbalize skin care needs

The nurse considers which factors when assessing the functional ability of a client? Select all that apply. Self-sufficiency Mobility Marital status Cognition Senses

Cognition Mobility Senses

When inspecting a wound, which factors should the nurse include in the assessment? Select all that apply. Color Temperature Size Discharge Location

Color Size Discharge Location

Molly was admitted to the medical unit and a vacuum-assisted wound closure device was applied to the wound. Molly asked how the device would help the wound heal. Which response by the nurse is most accurate?​ "Vacuum-assisted closure devices approximate the wound edges."​ "Vacuum-assisted closure devices provide nitrogen to the wound bed."​ "Vacuum-assisted closure devices keep the wound moist."​ "Vacuum-assisted closure devices ensure hydrogel ointment stays on the wound."​

"Vacuum-assisted closure devices approximate the wound edges."​

The nurse is completing a functional assessment on a client. The client asks what the purpose of the assessment is. How should the nurse respond? "It helps with insurance and billing." "It is used to complete nurse assignments." "It is used to identify ways to maintain independence." "It assists nurses in assigning rooms to clients."

"it is used to identify ways to maintain independence"

Which client is at greatest risk of developing a pressure injury? A middle adult client who is being treated following a minor motor vehicle crash An adolescent client with a spinal cord injury who can walk 50 feet in physical therapy daily A young adult client with diabetes mellitus who is admitted with a broken leg An older adult client who is hospitalized with bilateral hip fractures

An older adult client who is hospitalized with bilateral hip fractures

While assisting the client with bathing, the unlicensed assistive personnel (UAP) reports seeing a reddened area on the client's left hip. Which action should the nurse take first?​ Assess the client's skin thoroughly. ​ Document the findings as reported. ​ Request a wound nurse consult.​ Ask the UAP to pad the bony area. ​

Assess the client's skin thoroughly. ​

A nurse is assisting a client with a bed bath. What is the purpose of encouraging the client to wash themselves? Select all that apply. Saves time Bonds the staff with the client Encourages independence Assesses the client's abilities

Assesses the client's abilities Encourages independence

The nurse is assessing a client with a left-sided weakness and wants to gain insight into the client's instrumental activities of daily living (IADL) functional ability. What question would be most appropriate? "Are you able to shop independently for yourself?" "Can you get food from the plate to your mouth?" "Do you use any assistive device to ambulate?" "Do you know what today's date is?"

"Are you able to shop independently for yourself?"

Which statement made by a client during a 2-week postoperative clinic visit indicates a potential infection? Select all that apply.​ "There is yellowish drainage on the bandage that smells."​ "There is pale pink drainage on the bandage."​ "The wound is draining a clear, watery substance."​ "If I press around the sutures, it hurts."​ "Sometimes, the sutures itch."​

"If I press around the sutures, it hurts."​ "There is yellowish drainage on the bandage that smells."​

Which interventions should the nurse implement to prevent a pressure injury? Select all that apply. ​ Turn the client every two hours.​ Use a skin assessment tool per policy. ​ Pad the bony areas of the client's body with pillows.​ Inspect the skin around medical devices. ​ Tell the client to inform the nurse of any tingling in the lower extremities. ​ Increase the frequency of skin assessments.​

-Inspect the skin around medical devices. ​ -Turn the client every two hours.​ -Increase the frequency of skin assessments. ​-Use a skin assessment tool per policy. ​ -Pad the bony areas of the client's body with pillows.​

Which action violates medical asepsis when the nurse makes an occupied bed?​ Tucking clean linen against the frame of the bed Returning unused linen to a linen closet​ Wearing gloves when changing the linen Using the old top sheet for a new bottom sheet

Returning unused linen to a linen closet

Activity The degree of physical activity.

1. Completely Immobile

Mobility The ability to change and control body position.

1. Completely Immobile

Consider the following client: Mrs. Smith recently had a stroke with decreased sensation and limited movement of her left side. She is currently on bedrest and is unable to turn herself. Because she is going through menopause, Mrs. Smith perspires frequently, requiring her wet bed linens and gown to be change 2-3 times in 8 hours. Since her stroke, Mrs. Smith has trouble swallowing and is on a pureed diet with thickened liquids. Because she dislikes the consistency of her food and drinks, she is eating between 40% and 55% of meals and not snacking. *Be sure to write down the individual scores as you will need to calculate the total score at the end. Mrs. Smith's Braden Scale Score Based on your assessment of Mrs. Smith, what score would she receive on the Braden Scale? 15-16 = low risk 13-14 = moderate risk 12 or less = high risk

12 or less = high risk

Friction and Shear Select the score you believe to be the proper fit for Mrs. Smith's assessment.

1. Very Poor

From a nursing care perspective, the important assessment of a client's functional ability is the ability to perform the activities of daily living (ADLs), which include bathing, dressing, toileting, transferring (mobility), continence, and feeding. WORD BANK: complex in a healthcare facility routine while traveling basic least most at home

1. most 2. in a healthcare facility 3. basic

Oral Care The nurse is providing oral care to a client. Place the steps for cleaning the oral cavity in the correct order, from first to last. Roof of mouth, gums, and inside cheeks Chewing and inner tooth surfaces Outer tooth surfaces Tongue

1.Chewing and inner tooth surfaces 2. Outer tooth surfaces 3. Roof of mouth, gums, and inside cheeks 4. Tongue

A nurse enters a client's room to discuss discharge instructions and notes that the client is grimacing. This is considered a/an (severity of symptom, observation, or inspection.) The nurse asks the client to rate the pain on a scale of 0 to 10. The client rates pain at 6. This is considered a/an severity of (symptom, observation, or inspection.) The nurse assesses the client's surgical wound and notes that the area of separation is inflamed. This is considered a/an severity of (symptom, observation, or inspection.)

1.observation 2.severity of symptom 3.inspection

Nutrition The client's usual food intake pattern.

2. Probably Inadequate

While planning morning care, which client is the highest priority to receive a bath first? A client who prefers a bath in the evening when their spouse visits and can help A client who has just returned from diagnostic testing and complains of being very fatigued A client who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10 A client who is experiencing frequent incontinent diarrheal stools

A client who is experiencing frequent incontinent diarrheal stools

Which client's functional ability will be most impacted by their health? A client living with autism spectrum disorder A client with a right leg cast A client with drug-induced psychosis A client with bronchitis

A client with drug-induced psychosis

The nurse is providing a complete bed bath to a client using a commercial bath cleansing pack (bag bath). Which action taken by the nurse is used only when bathing clients with this type of product? Allow the skin to air-dry Avoid using a bath towel Rinse the skin thoroughly Dry the skin with a towel

Allow the skin to air-dry

A healthcare provider prescribes the following for a client with a right leg wound:​ Cleanse the wound with 30 mL of normal saline​ Pat dry​ Apply no-sting barrier to wound perimeter​ Apply water-based gel ointment to wound bed​ Cover with 6 × 6 dressing every day and as needed when soiled​ Keep the right leg elevated​ Which supplies will the nurse need to complete this wound care prescription? Select all that apply. Gloves Lidocaine 10 mL syringe Absorbent pads Povidone-iodine solution 4 x 4 gauze dressing Eye covering

Absorbent pads eye covering Gloves

Which clients require assistance with hygiene care? Select all that apply. A school-aged child who had heart surgery the previous day A young adult with severe grief after the death of a spouse An adult with upper extremity rigidity An adolescent who is confused A middle-aged adult with hypertension

An adolescent who is confused An adult with upper extremity rigidity A school-aged child who had heart surgery the previous day A young adult with severe grief after the death of a spouse

The nurse is planning care for an older adult client who weighs 43 kilograms, is confused, and has bilateral leg contractures. Which interventions should be included in the plan of care? Select all that apply.​ Turn the client every 4 hours.​ Keep linens dry and wrinkle free.​ Apply barrier cream as needed to the skin daily.​ Use a wedge pillow between the right and left legs daily.​

Apply barrier cream as needed to the skin daily.​ Keep linens dry and wrinkle free.​ Use a wedge pillow between the right and left legs daily.​

The nurse just completed making an occupied bed. Before stepping away from the client, how will the nurse ensure client safety? Select all that apply. Lower the bed to the lowest position Raise the head of the bed to 20 degrees Turn off all the room lights to let the client rest Raise the side rails Ensure the call light is within reach Apply the brakes on the bed

Apply the brakes on the bed Lower the bed to the lowest position Ensure the call light is within reach Raise the side rails

A nurse is planning a presentation about functional ability in older adults. Which statements should be included in the presentation? Select all that apply. Functional ability increases in older adults. Cognitive impairments affect dressing but not grooming. Assistive devices help clients maintain independence. Functional ability changes with illness. Functional ability lost during acute illness will not be regained.

Assistive devices help clients maintain independence. Functional ability changes with illness.

Select all the assessment findings that influence the client's hygiene care.​ An older adult client is on bed rest due to right-sided weakness from a recent stroke. The client is sitting in bed visiting with family. Heparin is infusing intravenously via an IV in the left upper arm.

Bed rest Right-sided weakness Recent stroke IV in the left upper arm

In what way does a bed bath benefit the client? Select all that apply. Exfoliate the skin Clean the client Improve circulation Assess the client's lungs

Clean the client Exfoliate the skin Improve circulation

A nurse is caring for a client with a sacral wound that is healing slowly. On day 8 of admission, the client reports an increase in pain and does not want to participate in physical therapy. During a dressing change, the nurse notices thick, purulent drainage and a foul odor coming from the wound, which has increased in size from the previous documentation.​ Which is the priority action for the nurse? Apply a wound dressing as per prescription. Contact the healthcare provider and re-evaluate the plan of care. Culture the wound for suspected infection. Document the findings of purulent drainage and a foul odor.

Contact the healthcare provider and re-evaluate the plan of care.

The nurse is caring for a client who had an abdominal surgery 2 days ago. Upon assessment of the incision, the nurse notes that it is open with tissue outside of the wound. Which action should the nurse take first? Palpate the protruding tissue for blanching. Contact the healthcare provider. Cover the wound with a sterile dressing soaked in sterile saline. Complete the dressing change and document findings.

Cover the wound with a sterile dressing soaked in sterile saline.

Pressure Injury The client just arrived at the emergency department (ED). The nurse observes the pressure injury seen at the left. Which aspect of the wound will the nurse assess to stage this pressure injury? Width of the wound Depth of the wound Presence of exudate Location of the wound

Depth of the wound

Which statements are true about handling bed linens? Select all that apply. When changing bed linen, follow principles of medical asepsis by keeping soiled linen away from the uniform. If clean linen touches the floor or any unclean surface, immediately place it in the dirty-linen container. Do not place soiled linen on the floor. Place soiled linen in special linen bags before placing it in a hamper. Gently shake the linen to check for personal belongings.

Do not place soiled linen on the floor. Place soiled linen in special linen bags before placing it in a hamper. If clean linen touches the floor or any unclean surface, immediately place it in the dirty-linen container. When changing bed linen, follow principles of medical asepsis by keeping soiled linen away from the uniform.

Which areas of Mike's body should the nurse closely observe for pressure injury? Select all that apply. ​ Back of the head and ears​ Hip Heels Shoulder​ Elbow​ Inner knees​ Lower back and buttocks

Elbow​ Shoulder​ Lower back and buttocks Back of the head and ears​ Heels

Bathing Order A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? Abdomen and legs Both arms and chest Eyes Buttocks and anus Perineal hygiene Back Face Hands and nails

Eyes Face Both arms and chest Hands and Nails Abdomen and Legs Perineal Hygiene Back Buttocks and Anus

Which actions are appropriate for the nurse bathing a client with dementia? Select all that apply. Encourage the client to bathe themselves while the nurse observes.​ Gather everything you will need for the bath before approaching the client. Use a supportive, calm approach and praise the client often. Help the client feel in control. Move quickly and let the person know when you are going to move the client.

Help the client feel in control. Use a supportive, calm approach and praise the client often. Gather everything you will need for the bath before approaching the client.

Case Study The nurse is caring for a 66-year-old client with a history of mild hearing loss and multiple sclerosis who is wheelchair-bound. The client is recovering from pneumonia and has developed a right trochanteric Stage 4 pressure injury at home. They have been receiving daily wound care and the wound is healing slowly. ​ The client performs scheduled urinary catheterizations and adheres to a daily bowel program. The client's dietary intake has been fair to good at home and is supplemented by protein drinks. Which assessment findings indicate that the client may be at risk of self-care deficit? Select all that apply.​ Hearing loss Urinary catheterizations​ Bowel program Illness Impaired mobility​

Illness Impaired mobility​

Drainage and Discharge Match the description with the type of drainage. Indicates possible infection Consists of blood and blood serum Indicates active bleeding Word bank: Purulent Serosanguineous Sanguineous

Indicates possible infection PURULENT Consists of blood and blood serum SEROSANGUINEOS Indicates active bleeding SANGUINEOUS

The nurse is caring for a client who begins to cry when the dressing from a leg wound is removed. The client states, "It hurts so much with the slightest touch." The nurse notes an odor and purulent drainage from the wound. Which is the most likely cause of these findings? Infection of the wound Migration of granulation tissue Nerve cell regeneration Analgesia before wound care was not provided

Infection of the wound

The nurse is preparing to give the client a partial bed bath. How should the nurse check the water temperature prior to performing the bed bath? Inner wrist Elbow Finger Hand

Inner wrist

While caring for a client who wears glasses to correct severely impaired vision, the unlicensed assistive personnel (UAP) notices the client is not wearing their glasses. Which action should the UAP take first? Place items within reach of the client. Provide large print materials. Introduce themselves when entering the client's room. Talk in a louder than normal voice.

Introduce themselves when entering the client's room

Case Study The nurse is caring for a 66-year-old client with a history of mild hearing loss and multiple sclerosis who is wheelchair-bound. The client is recovering from pneumonia and has developed a right trochanteric Stage 4 pressure injury at home. They have been receiving daily wound care and the wound is healing slowly. The client performs scheduled urinary catheterizations and adheres to a daily bowel program. The client's dietary intake has been fair to good at home and is supplemented by protein drinks. The client's pressure injury continues to heal. Since the client is at risk for impaired skin integrity, how long should the nurse schedule the client to sit in a chair? Less than 2 hours per occurrence​ Until the client expresses discomfort No more than 30 minutes every 2 hours Less than 3 hours daily​

Less than 2 hours per occurrence​

Review the following nurse's note: DateTimeProgress Note11/8/20XX08:00Client needs moderate assistance with hair hygiene and no assistance with feeding. What is the purpose for placing this note in the client's chart? For billing purposes For faster physical therapy evaluation For staffing purposes Maintain continuity of care

Maintain continuity of care

The client is on ordered bed rest and requires a linen change. Which actions will the nurse implement? Select all that apply.​ Turn the clean pillowcase inside out over the hand holding it. Apply sterile gloves. Make a modified mitered corner with the sheet, blanket, and spread. Keep soiled linen close to the uniform. Advise the client that they will feel a lump when rolling over.​

Make a modified mitered corner with the sheet, blanket, and spread. Advise the client that they will feel a lump when rolling over.​ Turn the clean pillowcase inside out over the hand holding it.

The nurse is preparing a client with a pressure injury for discharge. Which action can the nurse take to ensure the client and caregiver are able to perform the dressing change at home? Provide age-appropriate handouts. Observe a return demonstration of the dressing change. Pre-order dressing supplies that are delivered to the home. Plan a home health visit in 3 days.

Observe a return demonstration of the dressing change.

When planning care for several clients, which client should receive hygiene measures first?​ Middle adult female with a high fever and diaphoresis​ Middle adult male with a fractured femur and pain 8/10​ Young adult female who is menstruating​ Older adult male with frequent stool incontinence​

Older adult male with frequent stool incontinence​

A client who is paralyzed from the waist down, resides in a rehabilitation facility. What is the most appropriate bath for this client? Partial bed bath Complete bed bath Sitz bath Tepid bath

Partial bed bath

Based on age, which client is most likely to require assistance with hygiene? Adult Older adult Adolescent Preschooler

Preschooler

A nurse is delegating bed making to an unlicensed assistive personnel (UAP). Identify which statements provide proper delegation for the UAP and which statements would not be within their scope of practice (improper delegation). Proper Delegation or Improper Delegation Statements bank: "Help the client ambulate to the chair and then make the bed." "Restart the IV pump after you complete the bath." "Notify me if the client reports pain." "If you see blood on the bed linen, assess where it is coming from and notify me." "When making the bed, do not lay the client flat."

Proper delegation (tasks within the UAP's scope of practice): "When making the bed, do not lay the client flat." "Notify me if the client reports pain." "Help the client ambulate to the chair and then make the bed." Improper delegation: "Restart the IV pump after you complete the bath." - This is considered medication administration, which is a nursing responsibility and outside the UAP's scope of practice. "If you see blood on the bed linen, assess where it is coming from and notify me." - Assessment is a nursing function and is outside the UAP's scope of practice.

The nurse is caring for a client with a stage 4 pressure injury on the heel of the right foot. Which actions should the nurse take to protect the client's left heel from developing a pressure injury? Select all that apply. Provide a trapeze bar to facilitate movement in bed. Place a pillow under the client's feet. Massage reddened areas on the left heel. Establish an individualized turning schedule. Provide adequate nutrition and fluid intake.

Provide a trapeze bar to facilitate movement in bed. Place a pillow under the client's feet. Establish an individualized turning schedule. Provide adequate nutrition and fluid intake.

A client is admitted for pain control post knee replacement. The nurse observes that the client always washes the upper body before praying. How should the nurse interpret this behavior? Religious practice Personal preference Controlling behavior Anxiety

Religious practice

Discharge Planning A client with diabetes mellitus has special hygiene needs for nail and foot care to prevent injury and infection. Which discharge information should be given to the client and family to provide preventative hygiene care? Place the teaching instructions into the correct category. Safe and Appropriate Hygiene Practices or Unsafe Hygiene Practices Instructions Bank: Assess skin for redness and open areas daily. Wash hands frequently. Soak feet in hot water at least 10 minutes before nail care. Dry between toes after bathing. Involve family members in client education. Apply lotion to feet daily. Cut toenails and keep them short.

Safe and Appropriate Hygiene Practices: Assess skin for redness and open areas daily. Wash hands frequently. Dry between toes after bathing. Involve family members in client education. Apply lotion to feet daily. Unsafe Hygiene Practices: Cut toenails and keep them short. Soak feet in hot water at least 10 minutes before nail care.

Which are appropriate outcomes for the client while in the preoperative area? Select all that apply.​ The nurse will remain at the client's bedside continuously. ​ The client's skin will be clean and dry.​ The intravenous (IV) catheter access site will remain without signs of infection.​ The linen will be free of wrinkles and folds. ​

The linen will be free of wrinkles and folds. ​ The client's skin will be clean and dry.​ The intravenous (IV) catheter access site will remain without signs of infection.​

A nurse is caring for a client with a wound on the right arm. Which assessment finding requires immediate follow-up by the nurse? The odor from the wound noted after irrigation of the wound A moderate amount of serous drainage visible on the dressing The odor from the wound noted when standing at bedside The client correctly demonstrating how to perform a dressing change

The odor from the wound noted after irrigation of the wound

The nurse is caring for a client whose wound is healing by secondary intention. Which statement accurately describes this wound classification? The wound will be stapled together until it heals. The wound will heal quickly with minimal scarring. The wound will be left open and heal from the edges inward. The wound will be sutured after the current infection is controlled.

The wound will be left open and heal from the edges inward.

The nurse is caring for a young adult client admitted 3 days ago with pneumonia. The client has a history of injury leading to paraplegia 5 years ago and has smoked tobacco for the past 8 years. The assessment reveals that the client has lost 10 pounds in the last month and rarely uses the motorized wheelchair. Which risk factors are most likely to lead to impaired tissue integrity? Select all that apply. Immobility Age Tobacco smoking Poor nutritional status Diagnosis

Tobacco smoking Poor nutritional status Immobility

Which body area is best to accurately assess skin tone? Neck Inner thigh Foot/heel Under the upper arm

Under the upper arm

The nurse is caring for a client who presents to the emergency department (ED) with dehydration and fever. An assessment reveals a pressure injury on the left buttock covered with necrotic tissue that measures 8 cm (length) x 5 cm (width) x 0.5 cm (depth). How should the nurse stage this pressure injury? Stage 3 Stage 4 Stage 2 Unstageable

Unstageable

The nurse is providing eye care for a client who has experienced a stroke and has limited mobility in their hands. ​Demonstrate the proper technique for cleaning a client's eyes. On which side of the eye does the nurse start? Upper eyelid moving from nose outward. Upper eyelid moving from outer eye inward to nose Lower eyelid moving from outer eye inward to nose Lower eyelid moving from nose outward.

Upper eyelid moving from nose outward.

Which are risk factors that predispose a client to developing a pressure injury? Select all that apply. Family history of skin breakdown Malnutrition Immobility Altered perfusion Age greater than 65 years

altered perfusion malnutrition immobility age greater than 65 years

A nurse is caring for a client who is on complete bed rest, but has full function of all extremities. The nurse is providing the client with a partial bed bath. The perineal care for this client should be performed by the (nurse or client.)

client

Impaired Tissue Integrity​ Select all the primary assessment findings that are causing impaired tissue integrity. A nurse is caring for a client with diabetes mellitus who is scheduled for amputation of a necrotic left great toe. The client's WBC count is 9,000, and they have coolness of the lower extremities. The client weighs 75 lb more than their ideal body weight and smokes two packs of cigarettes a day.

diabetes mellitus coolness of the lower extremities. smokes two packs of cigarettes a day.

Wound Assessment The nurse's primary concern is (body image, infection, or need for more pain medication) and the action that the nurse should take is to (continue to observe, administer pain medication, or notify the healthcare provider.)

infection notify the healthcare provider

There are multiple options for treating head lice. The medication that is contraindicated in the pediatric population is called (lindane or pediculicide.) When using a fine-toothed comb there is a specific process that is recommended to remove lice. Which statement demonstrates that process? (Pull the comb from the bottom of the strand towards the scalp. or Place the comb as close to the scalp and comb away from the client's head.)

lindane place the comb as close to the scalp and comb away

08:00 Left dorsal ulcer 4 cm long x 2 cm wide, depth 0.2 cm without tunneling. Wound margins are well-defined. Scant serous exudate noted. Wound non-tender, no odor. ​Select the image below that depicts the type of drainage that is noted in the wound documentation.

white gauze with tint of light pink and watery (blood) Serous drainage

Important Clinical Findings From the scenario below, select the most important clinical findings. The nurse completed a dressing change for a client with a right lower leg wound from a fishing injury. During the dressing change, the nurse noticed that the wound has an odor, swelling and is warm to touch. The client stated pain at 2/10 and that they havebeen doing dressing changes at home and right before coming to the clinic. The client stated that the yellowish drainage started yesterday.

wound has an odor swelling is warm to touch yellowish drainage started yesterday.

Moisture The degree to which skin is exposed to moisture.

2. Very Moist

Which actions can the nurse take to protect the wound from further injury? Select all that apply. ​ Use pillows to pad the area.​ Apply extra dressing to absorb excess wound drainage.​ Turn the client frequently.​ Apply a negative pressure wound device to keep the area dry.​ Assess the opposite body area frequently.​

Use pillows to pad the area.​ Assess the opposite body area frequently.​Turn the client frequently.​

Which client is most appropriate for a moist to dry dressing (mechanical debridement)? Select all that apply. 24-year-old with an open, infected wound from a spider bite 50-year-old with a post-operative knee replacement incision ​​30-year-old who has necrotic tissue present in a crater type wound 7-year-old with an abrasion on bilateral knees from a bicycle accident 18-year-old with a leg fracture wound that was closed surgically

24 year old with an open infected wound from a spider bite 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound

Sensory Perception The ability to respond meaningfully to pressure-related discomfort.

3. Slightly impaired

When planning patient-centered wound care, the nurse should ensure that the planned outcome addresses which factor? Having a desire for specific healthcare interventions Having the same responses when compared to another client with a similar wound Achieving the highest possible level of wellness and independence in function Meeting the healthcare provider's specific client goals

Achieving the highest possible level of wellness and independence in function

The nurse completed a functional ability assessment on a newly admitted client. Sort the client data into the appropriate category. Activities of Daily Living or Instrumental Activities of Daily Living Client Data bank: Client can take medication in correct dosages at the correct time. Client can get clothes from a dresser. Client can heat food in a microwave. Client is partially incontinent of bladder. Client uses public transportation. Client can bathe self completely.

Activities of Daily Living: - Client can get clothes from a dresser. - Client can bathe self completely. - Client is partially incontinent of bladder. Instrumental Activities of Daily Living: - Client can take medication in correct dosages at the correct time .- Client uses public transportation .- Client can heat food in a microwave.

The nurse is caring for a client being discharged to home with a pressure injury. For each goal, identify if the goal is appropriate or not appropriate for the client. Appropriate Goals or Not Appropriate Goals Goals Bank: The client will verbalize signs of the wound infection to report to the provider. The client will maintain a normal nutritional and caloric intake. The client will avoid friction and shearing of the wound area. The client will maintain a dry wound healing environment. The client will report the pain level as well-controlled throughout wound healing. The client will change the wound dressing daily.

Appropriate goals: The client will verbalize signs of the wound infection to report to the provider. The client will avoid friction and shearing of the wound area. The client will report the pain level as well-controlled throughout wound healing. The client will change the wound dressing daily. Not Appropriate Goals: The client will maintain a normal nutritional and caloric intake. The client will maintain a dry wound healing environment.

A client with an indwelling urinary catheter has been given a bed bath by a new unlicensed assistive personnel (UAP). The nurse evaluating the cleanliness of the client notices crusting at the urinary meatus. Which action should the nurse take next?​ Remove the catheter Ask the UAP to observe while the nurse performs catheter care Leave the room and ask the UAP to go back and perform proper catheter care Tell the UAP that the incident will be reported to the nurse manager

Ask the UAP to observe while the nurse performs catheter care

Proper Order for Eye Care​ A client is unable to wipe their own face or perform eye care. Place the steps in providing eye care, while preventing infection and cross-contamination, in order from first to last. Assemble equipment and ensure the bed is at the correct working height. Moisten a washcloth and gently clean the upper eyelid from the medial canthus outward. Position the client sitting comfortably with the head tilted back. Using a clean portion of the washcloth or a new one, repeat the same process on the other eye. Assess the external and internal appearance of the eye for discharge, bruising, or inflammation. Decontaminate both hands and put on gloves.

Assemble equipment and ensure the bed is at the correct working height. Position the client sitting comfortably with the head tilted back. Decontaminate both hands and put on gloves. Assess the external and internal appearance of the eye for discharge, bruising, or inflammation. Moisten a washcloth and gently clean the upper eyelid from the medial canthus outward. Using a clean portion of the washcloth or a new one, repeat the same process on the other eye.

Mike Jones (preferred pronouns: he, him, his) is a 69-year-old client who was admitted with seizures. His medical history includes dementia, peripheral vascular disease, and diabetes mellitus type 1. He had a left dorsal ulcer noted on admission. He is prescribed strict bedrest and wound dressing changes once daily and as needed when soiled. Mike refuses to eat protein and is very selective about the items he will eat. His weight represents a healthy BMI. Nurse's Notes Date/TimeNURSE'S NOTES08/21/20XX08:00 Left dorsal ulcer 4 cm long x 2 cm wide, depth 0.2 cm without tunneling. Wound margins are well-defined. Scant serous exudate noted. Wound is non-tender with no odor. Risk Factors Which factors place Mike at an increased risk for developing a pressure injury? Select all that apply. Impaired perfusion Age Diabetes mellitus Dementia BMI with normal limits Bed rest

Bed rest Impaired perfusion Dementia Age Diabetes mellitus

Case Study The nurse is caring for a 66-year-old client with a history of mild hearing loss and multiple sclerosis who is wheelchair-bound. The client is recovering from pneumonia and has developed a right trochanteric Stage 4 pressure injury at home. They have been receiving daily wound care and the wound is healing slowly. The client performs scheduled urinary catheterizations and adheres to a daily bowel program. The client's dietary intake has been fair to good at home and is supplemented by protein drinks. While performing a thorough skin assessment, the nurse assesses the client's left heel and does not observe blanching of the skin. Why is blanching of the client's skin not observed?​ Blanching of the heel is not typically observed. ​ Blanching does not occur except when eschar is present. ​ Blanching only occurs in late-stage pressure injuries.​ Blanching does not occur in darkly pigmented ski

Blanching does not occur in darkly pigmented skin

Match the client with the type of bath that would be the most appropriate for them based on their clinical needs. Complete Bed Bath or Partial Bath Client Bank: Paraplegic with pressure ulcer Quadriplegic Client with femur fracture in Buck's traction Client chemically sedated client Client with cerebral palsy and upper extremity rigidity 96-year-old hospice client with bone cancer

COMPLETE BED BATH: chemically sedated client client with cerebral palsy Quadriplegic PARTIAL BATH: Paraplegic with pressure ulcer Client with femur fracture in Buck's traction 96-year-old hospice client with bone cancer

For each client, identify the associated risk factor for developing a pressure injury. Client on bed rest experiencing nausea and vomiting from chemotherapy Client with heat failure and lower extremity edema Client with a spinal cord injury Client with hip fracture Options: Impaired mobility Absent sensation Reduced perfusion Altered nutrition

Client on bed rest experiencing nausea and vomiting from chemotherapy: Altered nutrition Client with heat failure and lower extremity edema: Reduced perfusion Client with a spinal cord injury: Absent sensation Client with hip fracture: Impaired mobility

Client unable to sense, or has reduced sensation, caused by stroke, spinal cord injury, diabetes, or local nerve damage. Client unable to verbalize skin care needs Predisposition to impaired tissue synthesis Client unable to feel skin injury Moisture is medium for bacterial growth and causes local skin irritation

Client unable to feel skin injury

The nurse is performing hygiene measures for an older adult client and notes that the skin is wrinkled, thin, loose, and dry. Which factors contribute to this finding? Select all that apply. Reduced skin elasticity and decreased collagen Diminished inflammatory response Reduced subcutaneous padding over bony prominences Increased number of sweat and sebaceous glands Thickening of underlying muscle and tissues

Reduced subcutaneous padding over bony prominences Reduced skin elasticity and decreased collagen

Determining Functional Ability A client with a physical and cognitive impairment was just admitted to the unit from the Emergency Department. Which statement is true about the functional ability of this client? The client will require partial bed baths. The client will need total care and help with feeding. The client will perform their own grooming. The client's functional abilities need to be assessed.

The client's functional abilities need to be assessed

The nurse completing an admission assessment on a client with diabetes mellitus type 2 observes that the client is wearing dirty clothing and requires bathing and foot care. When questioned about hygiene habits, the client states they take a bath once a week and a sponge bath every other day. To provide care for this client, which principle should the nurse keep in mind?​ Clients who appear unkempt place little importance on hygiene practices. Personal preferences determine hygiene practices and are unchangeable. The client's illness may require teaching of new hygiene practices. All cultures value cleanliness with the same degree of importance.

The client's illness may require teaching of new hygiene practices.

Which actions should the nurse take regarding tunneling of the wound? Select all that apply.​ Measure the depth of tunneling using a tongue depressor.​ Measure the depth of tunneling using a sterile swab.​ Measure tunneling with each wound assessment.​ Measure the depth of tunneling in millimeter increments.​ Document tunneling using the ceiling as a reference point.​

Measure tunneling with each wound assessment.​ Measure the depth of tunneling using a sterile swab.​

Client Condition : Client has excessive secretions or excretions on the skin from perspiration, urine, watery fecal material, or wound drainage. Client has altered cognition resulting from dementia, psychological disorders, or temporary delirium. Client unable to verbalize skin care needs Predisposition to impaired tissue synthesis Client unable to feel skin injury Moisture is medium for bacterial growth and causes local skin irritation

Moisture is medium for bacterial growth and causes local skin irritation

The nurse is preparing to provide a complete bed bath for an unconscious client. The nurse decides to use a commercial bath cleansing pack (bag bath). In which order will the nurse clean the body, starting with the first area? ​ Abdomen Neck, shoulders, and chest Back of neck, back, and then buttocks and perineum Both arms, both hands, fingers and areas in between, and axilla Both legs, both feet, toes, and areas in between

Neck, shoulders, and chest Both arms, both hands, fingers and areas in between, and axilla Abdomen Right leg, right foot, and toes and areas in between Left leg, left foot, and toes and areas in between Back of neck, back, and then buttocks and perineum

A nurse is observing an unlicensed assistive personnel (UAP) changing the linens on the bed of a client who is immobile. Which action taken by the UAP requires intervention by the nurse? Lowers the side rail on the side of the bed closest to the UAP​ Reaches over the bed to straighten the fitted sheet​ Raises the bed to waist level​ Rolls the client to one side of the bed​

Reaches over the bed to straighten the fitted sheet​

The client used the call light and notified the unit clerk that their top sheet was wet. The nurse enters the room to change the sheets while the client remains in bed. In which order should the nurse complete the steps required to plan for changing the sheets on a client who is on bed rest? Arrange the steps in order, starting with the first. Organize supplies Review the client's medical record Perform hand hygiene and apply clean gloves Assess the room for safety

Review the client's medical record Organize supplies Assess the room for safety Perform hand hygiene and apply clean gloves

Case Study Review the client's electronic health record (EHR), then answer the question below. Patient Information Nurses' Notes Wound Assessment The nurse is caring for a 66-year-old client with a history of mild hearing loss and multiple sclerosis who is wheelchair-bound. The client is recovering from pneumonia and has developed a right trochanteric Stage 4 pressure injury at home. They have been receiving daily wound care and the wound is healing slowly. The client performs scheduled urinary catheterizations and adheres to a daily bowel program. The client's dietary intake has been fair to good at home and is supplemented by protein drinks. What type of bath would be recommended for this client?​ Sponge bath at the sink​ Shower​ Partial bed bath​ Complete bed bath​

Sponge bath at the sink​

Pressure Injury The client just arrived at the emergency department (ED). The nurse observes the pressure injury seen at the left. This pressure injury measures 5 cm x 7 cm and 3 cm deep. There is minimal bone exposed and minimal serosanguineous discharge noted on dressing. What stage is this pressure injury? Stage 1 Stage 2 Stage 3 Stage 4

Stage 4

As prescribed, the nurse leaves the pressure wound open to air and does not apply a dressing. Which stage of wound did the nurse appropriately treat? Stage I Stage II Stage III Stage IV

Stage I

The nurse is planning care for a client with a Stage 3 pressure injury measuring 4 cm in length, 2 cm in width, and 2 cm in depth. Which supplies should the nurse assemble to perform the wound irrigation? Sterile saline, 60 mL syringe, and sterile collection basin Dakin's solution, 20 mL syringe, and sterile gloves Povidone-iodine solution, sterile gloves, and non-sterile collection basin Non-sterile gloves, 10 mL syringe, and appropriate dressing

Sterile saline, 60 mL syringe, and sterile collection basin

The client was admitted to the medical-surgical unit for management of a stage 3 pressure injury on the right heel. What is an achievable outcome to maintain and promote skin integrity? Select all that apply. The client will use hot water and soap to clean the wound. The client will limit lotion use. The client will maintain a balanced, healthy diet. The client will use extra pillows to cushion bony areas. The client will reposition every 15 minutes.

The client will maintain a balanced, healthy diet. The client will use extra pillows to cushion bony areas. The client will reposition every 15 minutes.

An older adult client is on complete bed rest after a heart attack. The client has limited use of the right arm and a heparin intravenous (IV) infusion in the left upper arm. ​The client prefers bathing at night because it relaxes them before bed. They state that they prefer to clean their hands and upper body before every meal and that they use an electric razor at home.​ Which are achievable goals for this client? Select all that apply.​ The client will learn to use the right arm to shave. The client will use an adaptive measure to shave with the left hand. The client will learn to use a straight razor before discharge. The client will maintain intact clean skin.

The client will use an adaptive measure to shave with the left hand. The client will maintain intact clean skin.

The nurse is bathing a client and notices movement in the client's hair. Which action will the nurse take? Use gloves to inspect the hair. Apply a lindane-based shampoo immediately. Ignore the movement and continue. Shave the hair off the client's head.

Use gloves to inspect the hair.

Special devices are attached to wounds to promote healing. Knowledge about the purpose of each device and modality will guide wound care. Match the device with the purpose. Used to drain fluid from the body Used to keep wounds or independent limbs immobile Used to help wounds heal from inside out Special fibers used to close wounds; some can be absorbed by the body Used to apply negative pressure to the wound. Remove excess fluid. Used to bring wounds together, reduce edema, and removes fluid. Terms: Negative pressure wound device Vacuum assisted closure Binders/Slings Drains/Drainage evacuators Sutures/Suture glue Packing

Used to drain fluid from the body: Drains/Drainage evacuators Used to keep wounds or independent limbs immobile: Binders/Slings Used to help wounds heal from inside out: Packing Special fibers used to close wounds; some can be absorbed by the body: Sutures/Suture glue Used to apply negative pressure to the wound. Remove excess fluid.: Negative pressure wound device Used to bring wounds together, reduce edema, and removes fluid: Vacuum assisted closure

A client experiencing temporary functional ability of the right arm and hand will need assistance with which activities of daily living (ADLs) while hospitalized on a medical-surgical unit? Select all that apply. Washing the left arm Eating a sandwich Buttoning a shirt Securing Velcro shoes Washing clothes

Washing the left arm Buttoning a shirt

The nurse is caring for a client who is 36 hours postoperative from hip replacement surgery. Review the wound assessment notes, then answer the question. Nurse's Notes Date/TimeNURSE'S NOTES 08/21/20XX 04:00 Left hip sutures partially intact. Dressing and wound bed ​covered in a moderate amount of sanguineous drainage. ​Dressing reinforced. Pressure applied to suture site. Which complication does the nurse suspect? Dislodged eschar Wound tunneling Wound evisceration Wound dehiscence

Wound dehiscence