A nurse is caring for a client who has pneumonia.

Exhibit 1

Medication Administration Record

Day 1, 1500:

Cefazolin 500 mg every 12 hr IV

Dexamethasone 15 mg every 6 hr IV

Day 3, 1200:

Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily

Day 4, 1500:

Discontinue cefazolin 500 mg every 12 hr IV
The nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

A. Uses one pair of gloves for dressing removal and irrigation:

It is essential to change gloves between different steps of wound care to prevent cross-contamination and infection. Using the same pair of gloves for dressing removal and irrigation increases the risk of introducing pathogens into the wound, which can lead to infection.

B. Uses a syringe with a catheter for wound irrigation.

Using a syringe with a catheter for wound irrigation allows for controlled and precise delivery of the irrigation solution to the wound site. It helps ensure that the wound is thoroughly cleansed without causing excessive pressure or trauma to the surrounding tissue.

C. Administers an analgesic medication 5 minutes before starting irrigation:

While administering analgesic medication may help alleviate the client's pain during wound irrigation, it is not directly related to the procedural aspect of wound irrigation. Pain management is an essential component of wound care, but it does not demonstrate an understanding of the specific procedure of wound irrigation.

D. Refrigerates the solution before irrigation:

Refrigerating the irrigation solution is not necessary and may cause discomfort to the client when cold solution is used for wound irrigation. Wound irrigation solutions are typically used at room temperature to avoid temperature-related discomfort and to maintain the integrity of the solution.

A. Level of orientation:

The level of orientation refers to the client's cognitive status and ability to understand their surroundings. While important for overall assessment and care planning, it is not typically included in anthropometric assessment, which focuses specifically on physical measurements and characteristics of the body.

B. Respiratory rate:

Respiratory rate is a vital sign that reflects the client's respiratory status and is important for assessing oxygenation and ventilation. However, it is not part of anthropometric assessment, which primarily focuses on physical measurements related to body size, shape, and composition.

C. Weight

Anthropometric assessment involves the measurement of various body dimensions, such as height, weight, and body composition. Weight is a crucial component of anthropometric assessment as it provides information about the client's nutritional status, growth patterns, and overall health. Monitoring changes in weight over time can help identify trends and assess the effectiveness of interventions aimed at improving nutritional status or managing health conditions.

D. Current pain level:

Pain level is important for assessing the client's comfort and managing pain effectively, but it is not included in anthropometric assessment. Anthropometric assessment focuses on objective measurements of body dimensions and characteristics rather than subjective experiences such as pain.