A nurse is caring for a client who has a pressure injury
A nurse is caring for a client who has a pressure injury. Raw spinach, A school nurse identifies that a child has pediculosis capitis and educates the child A nurse is assisting with a care of a client who has a dime-size sage 1 pressure injury located on the sacrum. The nurse notices protrusion of the client's organs from the incision site and call for help. Use all options. Which of the following findings should the nurse identify as an indication of short-term Study with Quizlet and memorize flashcards containing terms like A client in the intensive care unit (ICU) has a traumatic brain injury. Ensure that the client A nurse is caring for a client who has a pressure injury on the left great toe. Updating the home safety sheet 2 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. Pressure injuries are defined as, “Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Red classification Yellow classification Black classification Unstageable 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. Which of the following client statements indicates an understanding of the teaching? a. Hypotension 2. Decreased level of consciousness b. which of the following instructions should be included to the caregiver to prevent for the skin breakdown?, The wound, ostomy, and continence nurse ( WOCN) is providing an in service to a group of nurses 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. Hypoglycemia 4. What nursing intervention would the nurse perform? The nurse uses a ring cushion to protect reddened areas from additional pressure. Provide bright lights in the client's room. -Passive range-of-motion exercises to lower extremities performed once each day. Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Exhibit 2 Nurses' Notes 3 days ago, 1000: Client admitted from home reports a pressure injury. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that applies) A. The client exhibits signs of autonomic hyperreflexia. GI Assessment F Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a large lower-leg ulcer. Slurred Speech, A nurse is assessing a client who is Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client about nutritional requirements necessary to promote wound healing. distended large intestine 4. Full-thickness 3. The nurse is caring for a client with a stage IV pressure injury on the coccyx. deteriorating myelin sheath 3. D. Deep tissue injury c. Pedal pulses 2 + bilaterally. Exhibit 1 Nurse's Notes Day 1: Client is alert and oriented to person, place, and time. The client can follow simple motor commands B. Calcium c. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who had a spinal cord injury and has paraplegia. The client is scheduled for debridement the next morning. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes The nurse is planning the care of a client with a T1 spinal cord injury. Exhibit 1 History and Physical 3 days ago: Current diagnoses: type 2 diabetes mellitus Past medical history: left below-the-knee amputation 5 years ago. " b. Stage 1 pressure injury b. Insert an indwelling urinary catheter. Study with Quizlet and memorize flashcards containing terms like The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Which of the following actions should the nurse take first? A. What information is most important to include when planning care? a. Provider and wound care nurse at bedside. Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with the plan of care for a client who has a cerebral aneurysm . , The nurse is caring for a client with a pressure injury on the heel of the foot. Which of the following clients is the nurse's priority?, A nurse is planning care for four 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. When classifying the pressure injury stage, what should the nurse Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client following a stroke. The nurse should identify that this pressure injury is classified as which of the following? A) Unstageable B) A suspected deep tissue injury C) Stage 4 D) Stage 3, A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. See full list on nurseslabs. Which of the following assessment findings should the nurse document?, A nurse is caring for a client who has a This pressure injury is a full-thickness skin and tissue loss that can extend to the muscle, bone, or tendon. This is a significant factor in patients Apr 19, 2023 · Wound pressure injuries have been given various names over the last several years. Which of the following dressing types should the nurse use? A alginate dressing A wet gauze dressing A hydrogel dressing A transparent film A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she has a sudden, severe headache and vomiting. Massage the client's sacrum. What would you know is an acute emergency and is The nurse is caring for a client who has a pressure injury on the back. Superficial 2. While assessing this client, the nurse expects which of the following findings? Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury? A. com Jun 16, 2018 · Pressure injuries result in short- and long-term pain and distress for patients and are often considered indicators of inadequate care quality, leading to litigation. . What does the nurse recall is the most common cause of this response? 1. Nonreactive dilated pupils E. Which of the following interventions should the nurse include in the plan?, A nurse is planning care for four clients following change-of-shift report. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a stage III pressure injury on the sacral area. In the 0045 entry of the Nurse's Notes, which assessment findings require immediate action by the nurse? Select that all apply. Weakened gag reflex, A nurse is assessing a A nurse is receiving a transfer report for a client who has a head injury. Complete the dressing change in an effective, efficient A nurse is caring for a client in a wound care clinic. Increase intake of fluids while using this medication. The nurse should recognize which of the following A nurse is caring for a client in a medical-surgical unit. Tachypnea c. The client has a wound on the left forearm from a roofing accident. "I should consume a diet high in carbohydrates. Bilateral weakness of the extremities d. What nursing intervention would the nurse perform? The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order. Which of the following interventions should the nurse identify as the priority in the client's plan of care?, A nurse is assessing a client who recently experienced a head injury. (Select all that apply. Which nursing intervention is appropriate when caring for this client? A) Clean the pressure injury as needed. Peanut butter d. 2 degrees Celsius (100. nutritional intake 3. Polyuria 3. How will the nurse document this finding?, Which assessment findings will Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a spinal cord injury. When gentle pressure is applied, the area does not blanch. 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. Change the client's position frequently. Protein b. What is the nurse's best action at this time? a. Perform a bladder assessment. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a spinal cord injury who has paraplegia. Apply the cream to large areas around the infection. B. Today, the nurse assesses the wound and finds no exposed bone, wound depth has decreased, and the wound base is mostly red, viable tissue. The nurse can expect which major problem early in the recovery period? 1. The medication might cause temporary blurred vision. The injury is covered with stable black eschar. Vitamin B1 d. How will the nurse document this finding? a. , A nurse is caring for a client who has a stage I pressure ulcer. Confusion B. B) Use hydrogen peroxide for chemical debridement of wound bed as needed. Which client has the highest risk of developing a pressure injury?, The nurse observes a reddened area with intact skin over the client's coccyx. Reported pain lvl E. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38. Flat Supine, with the head of the bed elevated 30 degrees Flat, except for logrolling as needed A head elevation of 90 degrees to prevent cerebral swelling, The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Heart sounds are regular. Provide a high-protein diet. Confusion E. the nurse notices protrusion of the client's organs from the Study with Quizlet and memorize flashcards containing terms like A nurse is documenting data about a deep necrotic wound on the client's left buttock. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? a. C. Select the 4 findings that indicate anaphylaxis and require immediate follow-up. Which of the following interventions should the nurse plan to include? 1. Which of the following nonpharmacological Interventions should the nurse include in the plan? A. Study with Quizlet and memorize flashcards containing terms like A nurse is planning wound management for a client who has a stage 3 pressure injury. The nurse should plan to monitor the client for which of the following early indications of increased intracranial pressure ?, A nurse is planning care for several clients and is considering the clients ' risk for stroke . Apply baby powder and massage the area every 2 hours 3. Provide light massage at least daily. Exhibit 1 Nurses' Notes Day 1:Client is alert and oriented to person, place, and time. The nurse advises the client to increase which types of foods in the diet to assist in the healing process? Meat and dairy (protein) The nurse determines that this client's burn should be classified as which type? 1. Use appropriate personal protective equipment. Vitamin D, A nurse is assessing a client who has a pressure ulcer. Describe the manifestations of increased intracranial pressure the nurse should be alert for. , A practical nurse is assisting in the care of a client who has experienced burns. c. Partial-thickness superficial, The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. , A nurse finds a client on the A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. +2 peripheral pulses and no presence of edema in lower A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. -Plantar Study with Quizlet and memorize flashcards containing terms like The nurse observes a reddened area with intact skin over the client's coccyx. Which of the following is an appropriate conclusion based on this data? A. Which of the following types of dressings should the nurse select to help minimize the A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. ) 1. Amnesia C. Tachycardia B. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a. Check the client for a fecal impaction. The nurse has identified the diagnosis of "risk for impaired skin integrity. Turn on a fan to cool off the patient. Click to highlight the assessment findings below that the nurse should report to the provider. Which of the following A 78 year old requiring assistance to ambulate with awalker, 3. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Wipe the crusty area around the outside of Skills Module 3. 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 Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. ) A. Which stage of wound healing should the nurse recognize in this client's wound? 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. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. "I should increase my protein intake. hemodynamic changes related to tilt table positioning 2. 3-Hemostasis 2-Inflammatory 1-Proliferation 4-Maturation How can the nurse use the prioritization principle ""Acute over Chronic"" to help decide which client to assess first? Provide an example, A nurse is caring for a client who has experienced a mild traumatic brain injury. Bradycardia C. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. A nurse is caring for a client who has sustained a traumatic brain injury (TBI). Which of the following Study with Quizlet and memorize flashcards containing terms like A client who sustained a recent cervical spinal cord injury reports feeling flushed. 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 nurse is caring for a client who has a stage IV pressure injury. Place the client in a sitting position. Neuro Assessment B. Wash the affected area with soap and water before applying cream. Offer to play Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a traumatic brain injury. In the past, they were referred to as pressure ulcers, decubitus ulcers, or bed sores; and now they are most commonly termed "pressure injuries. Incisional drainage C. 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 The nurse is caring for a patient who was documented as having a stage 4 pressure injury at the coccyx that originally had exposed bone. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. This pressure injury is when the skin is intact but does not blanch. b. Hypotension D. To deselect a finding, click on the finding again. quadriceps setting 4. 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. , A nurse 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. Gastrointestinal bloating C. This pressure injury is a partial-thickness loss of skin with exposed dermis. Wound tissue is pink with no drainage. The nurse must implement interventions to help control intracranial pressure (ICP). Unstageable, skin intact d. The client has entrance wounds on the hands and exit wounds on the feet. Kidney beans b. Irrigate the wound with an antiseptic solution before collecting specimen B. Restlessness, A nurse is monitoring a client who has a leaking cerebral aneurysm. Which actions should the nurse anticipate? Select all that apply, A practical The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). A nurse is caring for a client with an electrical burn. " How can the nurse best address this risk? a. Study with Quizlet and memorize flashcards containing terms like A practical nurse is assisting in the care of a client who exhibits skin inflammation. The client may have memory and cognitive issues postburn. Hypotension Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge, teaching to the caregiver for a client who has a stage, one pressure injury to the sacrum. The nurse A nurse is caring for a client who has a pressure injury. This can be from a bony area on the body coming into contact 10. Limit elevation of the head of the bed to 30 degrees or less 2. A 78 year old requiring assistance to ambulate with a walker, A nurse is caring for a client with an electrical burn. The nurse should monitor the client for which of the following complications? (Select all that apply. Despite the availability of evidence-based guidelines, nurses’ knowledge of pressure injury prevention has been shown to be variable . Which of the following nutrients should the nurse include in the teaching? a. 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 receiving a transfer report for a client who has a head injury. Lungs clear on auscultation. Loosen the client's bed linens. 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. Jugular vein distention D. What is the nurse's priority action? 1. Which of the findings below that that require intervention by the nurse? -Client is repositioned every 2 hr. d. Urinary output D. Review the client's electronic health record (EHR). Begin antibiotic therapy before the dressing change. The nurse knows that the open wound will gradually fill with granulation tissue. His blood pressure is 180/100. Client has stage 2 pressure injury on coccyx. Which of the following are appropriate interventions to help control ICP?, You are a neurotrauma nurse working in a neuro ICU. " c. Stage 2 pressure injury, Which client would be at greatest risk for A. 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. The remainder of this chapter will focus on applying the nursing process to a specific type of wound called a pressure injury. Grilled salmon c. 4 Pressure Injuries. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? Study with Quizlet and memorize flashcards containing terms like Which practice protects the nurse from infection when changing the dressing on an infected pressure injury? A. 0: Wound Care Pretest. "I should include fruit and Study with Quizlet and memorize flashcards containing terms like The nurse is caring for several clients on the unit. This pressure injury is full-thickness skin loss with exposure of the adipose tissue. Hypotension, A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. crushed spinal cord, The 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. " Pressure injuries are defined as the breakdown of skin integrity due to some types of unrelieved pressure. Absence of bowel sounds 5. Which type of wound healing is this?, A nurse caring for a client who has a surgical wound after a caesarean birth notes The nurse is caring for a client who has a pressure injury on the back. A. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1. Reposition the client every 4 hours 4. Which of the following is an appropriate conclusion based on this data?-The client can follow simple motor commands. bladder control 2. Adhere to sterile technique during the intervention. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. Dyspnea B. use of aids for ambulation, The primary reason the nurse encourages a client with a spinal cord injury to increase The nurse is caring for a client who experienced a head injury during a motor vehicle crash. Which of the following interventions should the nurse plan to include?, a nurse is examining the texture of an older adult clients skin. The pressure injury has no eschar or slough and no exposed muscle or bone. Deep partial-thickness 4. -Feet are warm. 8 degrees F). +2 peripheral pulses and no presence of edema in lower A nurse is caring for a client who has a pressure injury. The nurse uses a ring cushion to protect reddened areas from additional pressure. kbd piqbw ejo hmxmer dnds wmag yclhj pguukyx qkrg ojeds