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A nurse is preparing to apply a dressing for a client who has a stage 2
A nurse is preparing to apply a dressing for a client who has a stage 2. Apply non-sterile gloves: 2. A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Cleaning a Wound and Applying a Dry, Sterile Dressing. The nurse should recognize that which of the following statements by the clients partner A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Jugular veins distended. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing B) Increase the frequency of the dressing changes. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a wound infection. +2 peripheral pulses and no presence of edema in lower A nurse s selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. " D. Which of the following types of transmission precautions should the nurse initiate? 1. What should be the initial nursing action? 1. Bring a pitcher of fresh water to a client The charge nurse observes a new graduate nurse performing a dressing change on a client with a stage 2 left heel pressure injury. Which stage of wound healing should the nurse recognize in this client's wound? Study with Quizlet and memorize flashcards containing terms like outine nasal and rectal swabbing of a newly admitted hospital client has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the client is colonized with MRSA. -During this dressing change. Study with Quizlet and memorize flashcards containing terms like A nurse is completing a treatment on a client who has a stage 1 pressure ulcer. • Cleanse and irrigate wounds. Dressing supplies must be for single patient use only. • Obtain a wound culture specimen. Gather necessary equipment. Vitamin B1 D. cleanse with providone-iodine solution 4. -Apply a skin protectant to the skin around the incision. 9% sodium chloride. The nurse will follow which guideline for performing this procedure? If the wound is closed, clean technique may be used instead of sterile technique. What action should the nurse prioritize? a. Hand hygiene prevents spread of microorganisms. Have the client lie down for 15 minutes before wrapping. She is preparing to irrigate the eye with sterile normal saline solution. Check the client's pain level d. When preparing to irrigate the wound, which of the following actions should the nurse take first? a. Dropping sterile gauze onto the field from 1 in (2. Goal: The wound is cleaned and protected with a dressing without contaminating the wound area, without causing trauma to the wound, and without causing the patient to experience pain or discomfort. • Adapt procedures to reflect variations across the life span. "Help them onto their left side if they are experiencing nausea. Foul odor noted to urine. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. Sterile water is often the solution of choice when irrigating wounds. This action is supported by your right of self-determination. [32%] B. Use alcohol-based hand sanitizers on hands for at least 10 seconds. , A nurse is caring for a client who is unconscious. Client has stage 2 pressure injury on coccyx. Study with Quizlet and memorize flashcards containing terms like The nurse observes a reddened area with intact skin over the client's coccyx. Alginate. • Explain procedure to patient. Peanut butter d. Exhibit 1 Nurse's Notes Day 1: Client is alert and oriented to person, place, and time. During moderate sedation for a preschooler, which action would be most important? Keeping the room absolutely quiet so the child can sleep Keeping the child's head in a dependent position Asking the child to periodically count from 1 to 10 Assessing Study with Quizlet and memorize flashcards containing terms like A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. The nurse explains to the patient the purpose of the wound debridement, including which of the following? Select all that apply. It results in a A client arrives at the clinic and the nurse is performing an assessment. The nurse correctly recognizes that this is most likely because of which factor?, A nurse is caring for a client with a nonhealing stage IV pressure injury The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Don personal protective equipment C. Turn the client onto her or his operative side. Transparent. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Exposed bone, tendon, or Study with Quizlet and memorize flashcards containing terms like Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. , When Study with Quizlet and memorize flashcards containing terms like A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Which of the following instructions should the nurse include in the teaching Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a stage III pressure ulcer on the heel. Place a waterproof pad under the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an assistive personnel (AP). A. Schedule a follow-up visit by a home health nurse for dressing changes. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a stage III pressure ulcer on the heel. Which of the following actions by the new graduate indicates a need for further education about pressure injury care? a. The nurse should initially perform which action? A. Which action by the nurse demonstrates maintaining a sterile field? a. Hydrocolloid, Client has terminal illness and is at the end of life. Alginate- treat stage 3 and 4 pressure injuries to absorb drainage. IV site without redness or swelling. 5Keep the door of the room shut except Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Dry sterile dressing 4. stage 2, moderate. Use a soft chair or recliner for sitting. A nurse is providing discharge teaching to a client about self-administering heparin. Instruct the client about home disposal of contaminated dressings. Which instruction should the nurse include in the discharge teaching? 1. " C. ) A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Exposed bone, tendon, or Study with Quizlet and memorize flashcards containing terms like During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. Use an aqueous solution of aluminum acetate (Burow's solution) to wet the dressing. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. 2. Which of the following types of dressing should the nurse use 8. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to apply a prescription ointment to the client's wound. How should the A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. Hydrocolloid dressing promote healing in stage 2 pressure injuries by creating a moist wound bed. Use a sharp object to determine pain response C. Which of the following instructions should the nurse provide? A. Keep adhesive dressings in place for 6 weeks. Wound tissue is pink with no drainage. IV dressing dry and intact. Uses a hydrocolloid dressing (DuoDerm) to cover the wound b. D. Cleanse the wound with 0. Which of the following interventions should the nurse plan to include?, a nurse is examining the texture of an older adult clients skin. the nurse notices protrusion of the client's organs from the Study with Quizlet and memorize flashcards containing terms like The nurse prepares to irrigate a wound and apply antiseptic. Kidney beans b. [7%] E. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Study with Quizlet and memorize flashcards containing terms like A nurse is admitting a new client. Which action by the nurse would increase the risk for infection? a. Pouring the sterile solution slowly from 6 in (15 cm) above the container. ), A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change Study with Quizlet and memorize flashcards containing terms like A client has undergone a laparoscopic cholecystectomy. "Keeping the room warm will help them breathe easier. Which one of the following statements by the client's partner indicates effective coping? A. The injury is covered with stable black eschar. • Apply a variety of wound dressings. Empty the bile bag daily. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Which statement describes this phase of wound recovery?, The nurse is caring for a client who has reported to the emergency department with a steam burn on the right forearm. The nurse would monitor the dressing closely and would loosen the dressing if necessary. The client with acute glomerulonephritis who has oliguria and periorbital edema. Incontinence of stool 2. Intact skin 2. which of the following findings should the nurse report to the provider?, A nurse is performing a skin Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Gauze C. b. Keep liquids at the bedside. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes The nurse is preparing to complete a dressing change on a client with a Stage 2 pressure ulcer. Which of the following actions should the nurse take?, A nurse is using an open irrigation technique to irrigate a client's Question: 1 of 60 CORRECT Time Elapsed: 00:01:20 Pause Remaining: 08:20:00 PAUSE A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following wound dressing should the nurse apply to the ulcer? a. Use hot water when washing The nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. Day 2: IV site edematous. In addition, incontinent care A pressure dressing is not placed on the operative site because it may restrict breathing. Check the client's pain level D. Use non-sterile gloves to protect yourself from contamination. Report bile-colored drainage from any incision. When gentle pressure is applied, the area does not blanch. Which finding confirms the Study with Quizlet and memorize flashcards containing terms like A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. It stimulates cell growth and growth of new blood vessels. Airborne precautions 3. The client has a wound on the left forearm from a roofing accident. Which of the following assessments provides the most accurate measure of client's fluid status?, A nurse is teaching a client who has lower extremity weakness how to use a 4-point crutch gait. -The second postoperative day. Reassure the client that this is normal. Ecchymosis to sacral area. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? a. Make sure the pillow has a plastic . Which of the following actions is the nurse's priority? a. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. Hydrocolloid Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing the client's medical record. Perform hand hygiene: 3. Pack the wet dressing tightly into the wound. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. [2%], Which Study with Quizlet and memorize flashcards containing terms like Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a client's wound? Select all that apply. Place a waterproof pad under the A nurse is preparing to assist with irrigating a wound for a client. Apply light pressure over the area B. The client with renal calculi who is The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. The client's position should be changed a minimum of every 2 hours. Cover the wet packing with a dry sterile dressing. Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to apply an ace bandage to a client's left ankle after the client has been walking. , As a part of the senior citizen health program, the community health nurse arranges a free skin screening for the older The nurse should place a sterile, saline-soaked dressing over the client's wound to prevent the dressing from adhering to the tissue and protect the organs until the client is taken back to surgery. Call the surgeon. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. applying a new dressing with the gloves that were used to remove the old dressing d. Hydrocolloid. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Breath deeply into a paper bag when nauseated. 4Use soap and water, not alcohol-based hand rub, for hand hygiene. 3Wear gloves and gown while in the room caring for the client. , The nurse is explaining to the student nurse the difference between undermining and tunneling. WHat types of dressing should the nurse use? A. B) Pack a small piece of cotton deep into the client's ear canal. The burn is most likely: and more. Study with Quizlet and memorize flashcards containing terms like While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. What should the nurse include in the teaching? Select all that apply It allows for earlier ambulation after surgery. Which of the following types of dressing should the nurse use?, A nurse is caring for a client who has a terminal illness and is at the end of life. • Use appropriate aseptic or sterile technique. Which of the following actions should the nurse take while performing medication reconciliation?, A nurse is preparing to administer enoxaparin subcutaneously to a client. [32%] D. A client diagnosed with Alzheimer's disease has become more forgetful and has difficulty performing familiar tasks like bathing and dressing. Hydrocolloid b. -On day the surgery occurs. The client is surprised at this finding, since he enjoys generally robust health. Check present dressing with non-sterile gloves. A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hours post-op. Skin surrounding Study with Quizlet and memorize flashcards containing terms like The nurse performs a physical assessment on a client. Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. Obtain the prescribed irrigation solution B. C) Move the client's auricle down and back toward her head. What is the correct name of this wound?, During a dressing change, the nurse assesses protrusion of intestines through an A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? Hydrocolloid (Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. Study with Quizlet and memorize flashcards containing terms like Which phrase describes a hydrocolloid dressing?, When the primary health care provider prescribes cold therapy for a client, which adaptation would the nurse associate with the therapy's effect?, For a patient with a muscle sprain, localized hemorrhage, or hematoma, which would care product helps prevent edema formation, control Study with Quizlet and memorize flashcards containing terms like A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. Which nursing interventions would be helpful in managing this symptom? Select all that apply. which of the following dressing types should the nurse use?, a nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. Place a dry dressing in the wound. Which of the following instructions should the nurse include? A. Massage the area D. A nursing assistant enters the client's room and tells the nurse that a physician has telephoned and has asked to speak to the nurse. In planning client rounds, which client should the nurse assess first? 1. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?, A nurse is caring for a client who has an infected wound who has an infected wound removes a dressing saturated with blood and purulent drainage. Misplacing a valuable object 4. The stratum Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a pressure injury on the heel of the foot. Unstageable, skin intact d. 9% sodium chloride saline irrigation before obtaining the specimen. stage 4, end. Proteolytic enzyme Study with Quizlet and memorize flashcards containing terms like The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease should expect to observe which behaviors in this client? Select all that apply. Don personal protective equipment c. The client asks the nurse, "Do I have some kind of fungus growing on my skin? Identify the client using 2 identifiers. b) Put on clean gloves and A) Press gently on the tragus of the client's ear. Hydrocolloid dressings encourage a moist environment that is advantageous for wound healing, and provide protection against infection. Gauze. Exposed bone, tendon, or The nurse is assigned to clean a client's wound before applying a sterile dressing. ensuring that the surface where the sterile field will be set up is dry c. When should the PN reinforce teaching about the client's dressing change?-The morning of the discharge. stage 1, mild. The x-ray shows that the bone is The staff nurse reviews the nursing documentation in a client's chart and notes that the would care nurse has documented that the client has a stage 2 pressure injury in the sacral area. 4. Place a towel over the pillowcase. apply a heat lamp twice a day 3. Apply barrier cream to the area, While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of blood drainage on the surgical dressing, the client's skin is warm to the touch Study with Quizlet and memorize flashcards containing terms like A nurse is reinforcing teaching with the caregiver of a client who is near death. Which of the following instructions should the nurse include to promote comfort? Sleep on a firm mattress. When the solution from the wound turns light pink Study with Quizlet and memorize flashcards containing terms like Moderate sedation is a pain-management technique that is used with children. Documenting the characteristics of the wound D. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. 2Place a mask on the client when client is outside the room. Which of the following dressings should the nurse apply? 1. . checking that the A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Perform hand hygiene. Which of the following tasks should the nurse direct the AP to perform first? A. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply. Antimicrobial dressing, A client has a fractured tibia as a result of a fall. Which of the following explains why this is a concern? 1. Have the client remove the existing dressing while the nurse prepares sterile supplies (0%) 2. Which of the following foods should the nurse The nurse understands that a full-thickness graft is being applied instead of a split-thickness graft because of which reason?, The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. A nurse is caring for a client who has a pressure injury. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. Difficulty coming up with the right word Study with Quizlet and memorize flashcards containing terms like use pillows to maintain a side-lying position as needed (Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis C) Inflammatory phase D) Maturation phase, Upon responding to the The nurse is planning to perform a dressing change for a client with a stage three pressure ulcer. Calcium alginate d. The nurse would assist the client with deep-breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision. Tilt the client's head toward his left eye. d. a) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. Answer: D. The tissue easily bleeds when the nurse performs wound care. IV fluid infusing well. C) Replace the gauze with Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has end-stage pancreatic cancer. The nurse would assess the client as being in the stage of Alzheimer's disease labeled A. Collagen c. Change the transparent dressing on a client who has a stage 2 pressure ulcer B. It promotes wound healing and wound closure. After reviewing the image, what is the most important step for the nurse to take?, A nurse is providing care to several clients. -Apply a transparent dressing over the incision site. Have the client sit in a chair dangling before wrapping. Which of the following types of dressing should the nurse Study with Quizlet and memorize flashcards containing terms like A client has an odorous, purulent wound. Calcium C. What is the best nursing intervention at this time?, Which client would be at greatest risk for developing a pressure injury?, Which assessment findings will the nurse use to determine the stage of a A nurse is caring for a client in a wound care clinic. What is the priority nursing Study with Quizlet and memorize flashcards containing terms like A nurse is assisting in the care of a client who is being placed on transmission-based precautions. Opening the flaps of the sterile field toward oneself. Begin The nurse is preparing to change a client's sterile dressing. Which of the following nutrients should the nurse include in the teaching? A. Apply warm compresses to the ankle before wrapping. A nurse is caring for a client in a wound care clinic. I am not Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. SOME dressings (see “Selecting a Dressing” lesson) don’t require daily changes. Raw spinach, A school nurse identifies that a child has pediculosis capitis and educates the child Study with Quizlet and memorize flashcards containing terms like An older client is transferred to the nursing unit following a graft to a stage 4 pressure injury. [27%] C. Try jogging in place when joints feel stiff. The wound has a gauze dressing covering the area. Which steps are appropriate when performing the procedure? Select all that apply: 1. Which of the following actions should the nurse plan to take? - Irrigate the wound until that solution is draining is clear - Flush the wound from the most contaminated area to the cleanest area - Hold the tip of the syringe at least 1. Which client should the nurse assess first? 1. Which stage of wound healing should the nurse recognize in this client's wound? Study with Quizlet and memorize flashcards containing terms like The nurse is assigned to a patient who is preparing to go to surgery for wound debridement. 1Wear a mask if within 3 feet of the client. Droplet precautions 4. Place absorbent pads in the area of the The practical nurse (PN) is preparing to change the abdominal dressing for a client who had abdominal surgery yesterday. Administer the A nurse is planning to administer medication to a client who has Clostridium difficile infection. Administer prescribed oral pain medication A nurse is performing sterile wound irrigation for an assigned client. Gather all the necessary equipment B. Stage 2 pressure injury, Which client would be at greatest risk for Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a newly licensed about hand hygiene. The stratum corneum provides insulation for temperature regulation. A client requiring daily dressing changes of a recent surgical incision 3. Which actions should the nurse take? 1. Grilled salmon c. Irrigate the wound with an antiseptic prior to obtaining the The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. Which of the following types of dressing should the nurse use? A. " B. Which of the following actions should the nurse plan to take when caring for this client? Select all that apply, A nurse is assisting with caring for a female client who has a newly placed ileostomy, A nurse is caring for a client Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse plan to take to prevent transmission of this infection to others?-clean hands with an alcohol based hand rub immediately after removing gloves-Remove the cover gown in the client's room after providing care-place the client in a room with a negative The nurse notes that the client is in remodeling phase of wound repair. Forgetfulness of recent events 5. 5 in) above the wound while irrigating - Chill the irrigant prior to the procedure Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. B. The client has decided to forgo any additional treatment and be allowed to die. Which dressing is best for the nurse to use first?, What is the rationale for using the nursing process in planning care for clients?, A client with Raynaud's phenomenon asks the nurse about using biofeedback for Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has acute renal failure. Which response is best for the nurse to provide? Study with Quizlet and memorize flashcards containing terms like When changing a wet-to-dry dressing covering a surgical wound, what should the nurse do? A. The client with benign prostatic hypertrophy who has blood oozing from the intravenous site. Bowel sounds hyperactive. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing?, The nurse reinforces home care instructions with a client diagnosed with impetigo. Abdomen is tympanic. Click the card to flip ๐. Deep tissue injury c. , A client with acute Study with Quizlet and memorize flashcards containing terms like A nurse prepare to apply dressing for client with stage 2 pressure injury. • Assess tissue condition, wounds, drainage, and pressure injuries. Use all options. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. "Provide Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a large lower-leg ulcer. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. Vitamin D, A nurse is caring for a client who has a large lower-leg ulcer. , The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. With the help of an assistive personnel, the nurse has repositioned the client from a left lateral to a right lateral Study with Quizlet and memorize flashcards containing terms like The nurse is caring for the following clients on a medical unit. stage 3, moderate-severe. The burn is pink and has small blisters. Which statement indicates the need for The nurse would institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply. Which of the following actions should the nurse take? Clean the wound with 0. Protective environment 2. The nurse has removed the sutures and is now planning to apply wound closure strips. 1. Stage 1 pressure injury b. Protein B. After checking the physician's order, which actions should the nurse take next? Perform hand washing and check the client's identity. Contact precautions, Clients who have a compromised immune system Study with Quizlet and memorize flashcards containing terms like The nurse in the ED is caring for a client who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. Sep 25, 2023 ยท For a client with a Stage 2 pressure injury, it is generally recommended for a nurse to use a Hydrocolloid dressing. Apply ice packs to painful joints, A nurse Study with Quizlet and memorize flashcards containing terms like A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Wear clean gloves for removal and application of a new dressing (6%) 3. Confusion as to day and time 3. Alginate B. Study with Quizlet and memorize flashcards containing terms like A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. 5 cm Study with Quizlet and memorize flashcards containing terms like The nurse is assigned to care for four clients. describing each step verbally to the client before performing the dressing change b. Heart sounds are regular. This action is beyond my scope A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. What should the nurse do before applying the strips?-Apply a sterile gauze sponge over the incision site. Which of the following would the nurse recognize as a technique of inspection? Select all that apply. Dressing changes should be sterile to avoid introducing any new bacteria to the wound and to promote wound healing. Wound care and dressing changes should be performed at least daily or more often depending on orders. How will the nurse document this finding? a. c. There is a notation that states there is an absence of the stratum corneum. A client scheduled for a chest x-ray after insertion of a Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Cleanse with 0. Wet-to-dry dressing 3. Place the following steps in the order that the nurse should take when donning sterile gloves. Obtain the prescribed irrigation solution b. The client has silver plaques with reddening skin with rough raised flat tops on the scalp, creases of elbows, knees, and buttocks greater than 1 cm in diameter. The nurse should use warm water to wash hands to decrease the risk of removing protective oils from skin. -Apply a skin protectant to the incision site. Full-thickness skin loss 3. Which of the following types of dressing should the nurse use? Click the card to flip ๐ A nurse is caring for a client who has a stage II pressure ulcer. Transparent D. "Encourage meals at least three times daily. - Hyperlipidemia - Diabetes Mellitus - Medication History - Cholesterol Level - Prealbumin level, A nurse is preparing to assist with irrigating a wound for a client A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following responses should the nurse me to honor the clients request? A. A postoperative client preparing for discharge with a new medication 2. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? a. 9% sodium chloride irrigation. What should the client's nurse teach him about Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who sustained a chemical burn in his right eye. The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. Transparent dressing 2. 3. When there are several risks to client safety, the one posing the greatest threat is the highest priority. 3 cm (0. Study with Quizlet and memorize flashcards containing terms like A client is admitted with a stage four pressure injury that has a black, hardened surface (eschar) that is stable. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with Study with Quizlet and memorize flashcards containing terms like The nurse is teaching a client the reasons for use of negative pressure wound therapy (NPWT). Lungs clear on auscultation. Learning Objectives. C. Massage reddened areas during dressing changes. Use non-sterile gloves to remove the old dressing. Which nding would the nurse expect to note on assessment of the client's sacral area? 1. How does the nurse best support this client? Changes the dressing frequently Encourages a diet high in protein Suggests whirlpool therapy Places room deodorizers in the room, The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus Study with Quizlet and memorize flashcards containing terms like Which action should the nurse perform when applying negative pressure wound therapy?, An obese client on the unit has demonstrated difficulty healing a large pressure injury.
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