Patient Data
Review was done of H and P, nurses' notes, and orders.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Pressure sores are divided into different stages:
Stage 1= Intact skin with non-blanchable redness over a localized area
Stage 2= Partial thickness loss of dermis, shallow open ulcer with a pink base
Stage 3= Full thickness ulcer but tendons, muscles and bone are not exposed
Stage 4- Full thickness wound with exposed tendons, muscle and bone
Unstageable-Full thickness tissue loss with the base covered with an eschar or yellow, gray or brown tissue
The client already has a pressure sore that requires cleaning to remove any tissue debris that may act as nidus for infection, placing a hydrocolloid dressing protects and debrides the wound to promote healing Monitoring skin integrity is key to ensure no other pressure sores develop.
Nutritional status determines the risk of developing pressure injury and the chances of wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reduced lung sounds could indicate consolidation in a pneumonic process
B. Contraction of the left pupil upon shining light into the right is a normal response referred to as the consensual pupillary response
C. Active bowel sounds are a normal finding and not considered an exception.
D. A capillary refill time within the normal range (usually less than 2 seconds) is a normal finding and not considered an exception.
Correct Answer is ["B","C","D"]
Explanation
B. Implementing a 24-hour schedule of routine analgesic administration ensures consistent pain control and helps prevent breakthrough pain.
C. Determining the client's subjective measure of pain using a numerical pain scale allows the nurse to assess the severity of the pain and monitor changes over time, which is essential for effective pain management.
D. Providing comfort measures such as topical warm application and tactile massage can help alleviate pain and provide relief to the client. These measures are non-pharmacological interventions that can complement analgesic therapy and improve the client's comfort level.
A. Encouraging increased fluid intake can help prevent dehydration and promote overall well-being, but it may not directly address chronic pain management. However, monitoring urinary output is important for assessing hydration status and renal function.
E. Encouraging mobility and physical activity is important for maintaining overall function and preventing complications associated with immobility. However, it may not directly address chronic pain management.
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