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. Hand hygiene, including washing hands before and after handling needles and syringes, is a fundamental component of standard precautions. It helps reduce the risk of transmitting pathogens between the client and the healthcare provider.
B. While wearing gloves is important for protecting oneself from potential exposure to bloodborne pathogens, it is part of personal protective equipment (PPE) precautions rather than standard precautions. Standard precautions primarily focus on hand hygiene and barrier precautions such as gloves, gowns, and masks when appropriate.
C. Wearing a face mask is not typically necessary for routine administration of medications, unless there is a risk of splashes or sprays of blood or body fluids. While it's important to protect mucous membranes from exposure to potentially infectious materials, the routine use of a face mask for medication administration is not a component of standard precautions.
D. This action is unsafe and does not demonstrate an understanding of standard precautions. Removing the needle before discarding the syringe increases the risk of needlestick injuries. Proper needle disposal involves keeping the needle intact with the syringe and disposing of them together in a puncture- resistant container.
Correct Answer is A
Explanation
A. Encouraging the client to visualize positive external places, such as peaceful landscapes, serene beaches, or tranquil gardens, can help distract from the pain and promote relaxation. This focus can help shift the client's attention away from the pain sensation, potentially reducing its intensity and improving overall comfort.
B. Tranquil sounds can be utilized but are not a form of guided imagery.
C. Emotional reflection (choice C) may not directly contribute to pain relief during guided imagery sessions.
D. Incorporating motivational phrases during guided imagery can help boost the client's mood, enhance self-confidence, and foster a positive mindset, which may contribute to pain relief and overall well- being. However, positive external places should be the primary focus.
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