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 D
Explanation
D. Edema of the fingers and hands can impair circulation and peripheral perfusion, which may affect the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edema can interfere with the transmission of light through the tissues, leading to inaccurate readings.
A. A strong radial pulse volume indicates adequate peripheral perfusion and may not directly contribute to a lower oxygen saturation reading.
B. A capillary refill time within the normal range (typically less than 2 seconds) suggests adequate peripheral circulation and may not directly contribute to a lower oxygen saturation reading.
C. While hypertension can potentially affect oxygen saturation through its impact on systemic vascular resistance and tissue perfusion, a blood pressure of 142/88 mm Hg alone may not significantly contribute to a lower oxygen saturation reading.
Correct Answer is D
Explanation
D. Wearing gloves during this part of the procedure helps prevent contamination of the specimen and reduces the risk of transmission of pathogens to the nurse. It is important to maintain aseptic technique when obtaining a urine specimen from an indwelling urinary catheter to ensure accurate test results and prevent infection.
A. Recording the output on the flowsheet typically does not require wearing gloves, as it involves writing on paper or electronic documentation.
B. Clamping the urinary catheter may involve direct contact with the catheter tubing, which could potentially be contaminated with urine or other bodily fluids.
C. Transporting the urine specimen involves handling the specimen container or biohazard bag, which may potentially be contaminated with urine. Gloves should be worn during this step to prevent direct contact with the specimen and reduce the risk of exposure to pathogens.
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