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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. Securing Velcro shoes E. Calcium alginate d. Verbal communication consists of which 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? A. After checking the physician's order, which actions should the nurse take next? Perform hand washing and check the client's identity. Client has stage 2 pressure injury on coccyx. Which of the following assessment findings should the nurse identify as an indication of a hypersensitivity reaction to the phenytoin? a) enlargement of the cervical lymph nodes b) diarrhea c) ringing in the ears d) alopecia, A nurse is caring for Study with Quizlet and memorize flashcards containing terms like A nurse is reinforcing teaching with the caregiver of a client who is near death. The nurse is caring for a client who is to have a sterile dressing change to a wound. The nurse notices protrusion of the client's organs from the incision site and call for help. Instruct the client about home disposal of contaminated dressings. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. b. "Provide 1. Change the transparent dressing on a client who has a stage 2 pressure ulcer 2. 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 The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. Skin surrounding Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a newly licensed about hand hygiene. Indirect contact, A nurse is caring for a client who is on contact precautions Study with Quizlet and memorize flashcards containing terms like Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. Which of the following instructions should the nurse include in the teaching 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. A student nurse enters the client's room and notices the nurse preparing the sterile field. A) Press gently on the tragus of the client's ear. Which of the following wound dressing should the nurse apply to the ulcer? a. Calcium C. Bring a pitcher of fresh water to a client 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 instructions should the nurse provide? A. Airborne D. Which of the following actions should the nurse take?, A nurse is using an open irrigation technique to irrigate a client's 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. Cover the ulcer with an occlusive transparent dressing. Check the client's pain level D. Direct contact B. Which of the following foods should the nurse . The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. , What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing?, A nurse is cleaning the wound of a client who has been injured The nurse has removed the sutures and is now planning to apply wound closure strips. Documenting the characteristics of the wound D. What is the priority nursing A nurse is caring for a client who has a stage II pressure ulcer. Clean the ulcer with hydrogen peroxide and leave it open to the air. The injury is covered with stable black eschar. Washing the left arm C. Place a waterproof pad under the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has acute renal failure. . When gentle pressure is applied, the area does not blanch. By allowing the client to demonstrate learning, which type of educational learning has been practiced? 1. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who started a prescription for phenytoin 3 weeks ago. Place a towel over the pillowcase. When the solution from the wound turns light pink 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. 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 A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an assistive personnel (AP). Vitamin D, A nurse is caring for a client who has a large lower-leg ulcer. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. "Help them onto their left side if they are experiencing nausea. Eating a sandwich D. A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. How will the nurse document this finding? a. C. Assess current dressing. The stratum corneum provides insulation for temperature regulation. Transport a client to the radiology department for a routine chest X-ray. Which of the following IV fluids does the nurse anticipate a prescription for and why? 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. Gather all the necessary equipment B. 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. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. +2 peripheral pulses and no presence of edema in lower A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following tasks should the nurse direct the AP to perform first? A. Which of the following actions by the new graduate indicates a need for further education about pressure injury care? a. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing B) Increase the frequency of the dressing changes. Washing clothes, The Study with Quizlet and memorize flashcards containing terms like A nurse is removing the staples from a client's surgical incision, as ordered. Which type of wound healing is this?, A nurse caring for a client who has a surgical wound after a caesarean birth notes A nurse is caring for a client who is in early stage renal failure and has a prescription for the infusion of IV fluids. The client's position should be changed a minimum of every 2 hours. The nurse should recognize that which of the following statements by the clients partner The charge nurse observes a new graduate nurse performing a dressing change on a client with a stage 2 left heel pressure injury. What should the nurse do before applying the strips?-Apply a sterile gauze sponge over the incision site. Turn and reposition the client every 2 hours. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Alginate- treat stage 3 and 4 pressure injuries to absorb drainage. Stage 1 pressure injury b. Bring a pitcher of fresh water to a client who has just had a lumbar puncture. A nurse has demonstrated the proper cleaning and dressing change techniques for a client's postoperative wound. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure? 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. a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. Exposed bone, tendon, or Study with Quizlet and memorize flashcards containing terms like A client has an odorous, purulent wound. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. Click the card to flip 👆. Answer: D. c. Study with Quizlet and memorize flashcards containing terms like 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. Biofeedback B. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. Feverfew D. See full list on nurseslabs. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. Which of the following actions is the nurse's priority? a. A. Droplet C. b) Put on clean gloves and Sep 25, 2023 · For a client with a Stage 2 pressure injury, it is generally recommended for a nurse to use a Hydrocolloid dressing. 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. Aloe C. Protein B. D. B. 3. " C. com A guide to the form and function of wound dressings by composition is ofered to aid clinicians in appropriate dressing selection to match the characteristics of the wound for optimal healing outcomes. Which of the following explains why this is a concern? 1. Buttoning a shirt B. 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 a pressure injury on the heel of the foot. Use alcohol-based hand sanitizers on hands for at least 10 seconds. If you plan to touch the dressing, donne non-sterile gloves to protect yourself from exposure to BBF. Which stage of wound healing should the nurse recognize in this client's wound? A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. A nurse is providing discharge teaching to a client about self-administering heparin. IV site without redness or swelling. What is the correct name of this wound?, During a dressing change, the nurse assesses protrusion of intestines through an Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client about nutritional requirements necessary to promote wound healing. The tissue easily bleeds when the nurse performs wound care. Make sure the pillow has a plastic 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. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. When preparing to irrigate the wound, which of the following actions should the nurse take first? a. Assess dressing for signs of shadowing / bleeding, type and size of dressing used. In planning client rounds, which client should the nurse assess first? 1. Lungs clear on auscultation. The stratum 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. 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 The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. 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 A nurse is caring for a client in a wound care clinic. C) Replace the gauze with A nurse is performing sterile wound irrigation for an assigned client. Which of the following types of dressing should the nurse use 8. Wound tissue is pink with no drainage. Study with Quizlet and memorize flashcards containing terms like A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. - Hyperlipidemia - Diabetes Mellitus - Medication History - Cholesterol Level - Prealbumin level, A nurse is preparing to assist with irrigating a wound for a client 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. "Encourage meals at least three times daily. Administer prescribed oral pain medication 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 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. Don personal protective equipment c. "Keeping the room warm will help them breathe easier. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Provide the client with a diet high in vitamin C, zinc, and protein. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. What precaution will the nurse take while performing this dressing change? a) Apply a mask. Deep tissue injury c. Apply non-sterile gloves: 2. Transparent. 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 A nurse is admitting a new client. Obtain the prescribed irrigation solution b. Use hot water when washing The nurse is planning to perform a dressing change for a client with a stage three pressure ulcer. The nurse should inform the client that this condition is a contraindication for which of the following therapies A. 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. 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. " D. 2. Which of the following types of dressing should the nurse Study with Quizlet and memorize flashcards containing terms like Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. Sterile water is often the solution of choice when irrigating wounds. Hydrocolloid b. 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 reviewing the client's medical record. Intact skin 2. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? A. The wound has a gauze dressing covering the area. Alginate. Uses a hydrocolloid dressing (DuoDerm) to cover the wound b. Vitamin B1 D. 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 A nurse is caring for a client who has a pressure injury. Acupuncture The nurse is preparing to complete a dressing change on a client with a Stage 2 pressure ulcer. Unstageable, skin intact d. Don personal protective equipment C. The client has a wound on the left forearm from a roofing accident. Initial nursing management includes calling the health care provider and:, The nurse would recognize which client as being particularly susceptible to impaired wound healing?, A medical-surgical nurse is assisting a wound care nurse A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. Which statement indicates the need for Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with teaching a newly licensed nurse about infectious agents. C) Move the client's auricle down and back toward her head. The nurse has the client then demonstrate the proper technique and repeat when to change the dressing and why. " B. Proteolytic enzyme 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. A client requiring daily dressing changes of a recent surgical incision 3. Exhibit 1 Nurse's Notes Day 1: Client is alert and oriented to person, place, and time. In addition, incontinent care Study with Quizlet and memorize flashcards containing terms like The nurse is assigned to care for four clients. c) Place soiled dressings directly in the trash. Day 2: IV site edematous. b) Don disposable gloves. Cognitive 2 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. The nurse should initially perform which action? A. Use non-sterile gloves to remove the old dressing. Collagen c. Obtain the prescribed irrigation solution B. Schedule a follow-up visit by a home health nurse for dressing changes. Heart sounds are regular. Perform hand hygiene. Keep liquids at the bedside. The nurse will follow which guideline for performing this procedure? If the wound is closed, clean technique may be used instead of sterile technique. Stage 2 pressure injury, Which client would be at greatest risk for 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. 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 Study with Quizlet and memorize flashcards containing terms like Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. d) Use sterile technique. A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hours post-op. Perform hand hygiene: 3. -Apply a skin protectant to the skin around the incision. 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. There is a notation that states there is an absence of the stratum corneum. The nurse should use warm water to wash hands to decrease the risk of removing protective oils from skin. What is the nurse's best action? Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple Study with Quizlet and memorize flashcards containing terms like A nurse is learning about communication concepts and techniques. 1. B) Pack a small piece of cotton deep into the client's ear canal. Full-thickness skin loss 3. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which of the following instructions should the nurse include? A. 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 Study with Quizlet and memorize flashcards containing terms like The nurse prepares to irrigate a wound and apply antiseptic. 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. -Apply a skin protectant to the incision site. A postoperative client preparing for discharge with a new medication 2. Study with Quizlet and memorize flashcards containing terms like The nurse observes a reddened area with intact skin over the client's coccyx. Hydrocolloid. Check the client's pain level d. which of the following types of dressing should the nurse use Your solution’s ready to go! Enhanced with AI, our expert help has broken down your problem into an easy-to-learn solution you can count on. IV dressing dry and intact. Change the transparent dressing on a client who has a stage 2 pressure ulcer B. 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. Hydrocolloid dressings encourage a moist environment that is advantageous for wound healing, and provide protection against infection. 4. Hand hygiene reduces risk of spread of microorganisms. Hydrocolloid dressing promote healing in stage 2 pressure injuries by creating a moist wound bed. 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. Place a waterproof pad under the 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. -Apply a transparent dressing over the incision site. 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 nutrients should the nurse include in the teaching? A. IV fluid infusing well. Gauze. Which nursing interventions would be helpful in managing this symptom? Select all that apply. Take an arterial blood gas specimen to the laboratory. The nurse knows that the open wound will gradually fill with granulation tissue. Which statement by the nurse is correct about intrapersonal communication?, In the communication process, what does the nurse understand the "channel" to be?, Verbal communication is a key process for caring for clients. Which of the following actions should the nurse take while performing medication reconciliation?, A nurse is preparing to administer enoxaparin subcutaneously to a client. Which is the priority nursing action? 1.
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