Download NR 224 WEEK 3 WITH COMPLETE SOLUTIONS 100% VERIFIED!! and more Exams Advanced Education in PDF only on Docsity!
NR 2 24 WEEK 3 WITH COMPLETE SOLUTIONS 100 % VERIFIED!!
Stage 1 pressure ulcer - ANSWER non-blanchable erythema of intact skin
stage 2 pressure ulcer - ANSWER partial thickness skin loss involving epidermis, dermis, or both
stage 3 pressure ulcer - ANSWER full thickness tissue loss with visible fat
stage 4 pressure ulcer - ANSWER Full-thickness tissue loss with exposed bone, muscle, or tendon
unstageable pressure ulcer - ANSWER base of ulcer covered by slough and/or eschar in the wound bed. -necrotic tissue
slough - ANSWER yellow subcutaneous fatty tissue
eschar - ANSWER tan, brown, or black tissue that is dry, thick, or leathery
serous drainage - ANSWER clear to light pink and is watery -normal and it's a sign that your body is healing
sanguineous drainage - ANSWER Bright red; indicates active bleeding
serosanguineous drainage - ANSWER pinkish-red and watery; a mix of clear and red fluid
Primary intention healing - ANSWER edges remain close (well approximated) heals quickly, without minimal loss of tissue ex: surgical wound closed by sutures
secondary intention healing - ANSWER wound in which the tissue surfaces are not approximated and there is extensive tissue loss -the wound will be left open and heal from the edges inward ex: pressure injury, burn
Dehiscence - ANSWER partial or total separation of wound layers
Evisceration - ANSWER dehiscence that involves the protrusion of visceral organs through a wound opening
purulent drainage - ANSWER thick green, yellow, or brown drainage -sign of infection
Hydrogel dressing - ANSWER contain a large amount of water that keeps ulcers moist rather than letting them become dry.
hydrocolloid dressing - ANSWER used in the treatment of non-infected, mildly exuding wounds, such as minor burns or pressure ulcers, also known as bed sores.
foam and alginate dressings - ANSWER for wounds with large amounts of exudate and those that need packing
transparent dressing - ANSWER protects redness from opening up -used for stage 1
transportation medication handling finances
sequence for giving a bath - ANSWER eyes face arms and chest hands and nails abdomen and legs perineal (genital area) back buttocks and anus
Who is at highest risk for a bath? - ANSWER A patient with incontinent stools because they are at a greater risk for skin breakdown
what are indicators that a client may require assistance with bathing? - ANSWER Physical impairment Cognitive impairment Emotional distress
Highest priority for bed making and bed bath - ANSWER keep a patient clean, dry, and comfortable
complete bed bath - ANSWER bath is given to totally dependent clients in bed ex: sedated, cerebral palsy, quadriplegic (paralyzed in all 4 limbs)
Partial bed bath - ANSWER bathing only body parts that would cause discomfort if left unbathed like hands, face, axilla
-used for bedridden and dependent clients ex: extensive pain, hospice, paraplegic (paralyzed from the waist down)
sponge bath at sink - ANSWER client is sitting in a chai, can perform a portion of the bath independently, the nurse helps with hard to reach areas ex: lung issues, tire easily, muscle weakness, devices that can't be removed
disposable bath - ANSWER used for clients with specific bacteria or infections with multi-drug resistant organisms
UAPs do not have the authority to - ANSWER assess, manage, IVs, or administer medications
What is the next step done by the nurse if a UAP incorrectly does something? - ANSWER ask them to observe you doing the task, ensuring they have been shown how to properly do it
Check the temperature of the bath using the... - ANSWER inner wrist -this is the thinnest part of the skin
What indicates immediate follow up by the nurse after irrigation of a wound? - ANSWER odor
- this may indicate infection
Risk factors for pressure injury - ANSWER impaired mobility impaired sensory perception fecal or urinary incontinence poor nutrition impaired LOC
actions that promote pressure injury prevention - ANSWER provide a trapeze bar to facilitate movement in bed adaquete nutrition and fluid intake establish an individualized turning schedule placing a pillow under the clients feet
Risk factors for impaired tissue integrity - ANSWER immobility tobacco smoking poor nutritional status
Blanchable - ANSWER red when it blanches, turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed
Non-blanchable - ANSWER skins stay very red even with finger pressure; indicates severe skin injury
Chelitis - ANSWER inflammation of the lips -cracked lips
Edentulous - ANSWER lacking teeth
effleurage - ANSWER a form of massage involving a circular stroking movement made with the palm of the hand.
Maceration - ANSWER the softening and breaking down of skin as a result of prolonged exposure to moisture
Xerostomia - ANSWER dry mouth
patients at risk for dehiscence - ANSWER poor nutritional status infection diabetes PVD
what to do when evisceration occurs - ANSWER place soaked sterile gauze over the organ contact surgery team place patient on NPO observe for s/s of shock prepare patient for emergency surgery
what is indicated when a reddened area blanches on fingertip touch? - ANSWER the attempt by the body to overcome an ischemic episode
how to reduce tissue damage from shearing? - ANSWER use a transfer device have the HOB flat when repositioning a client raise the HOB 30 degrees when a patient is lying supine
which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? - ANSWER provision of support to abdominal tissues when coughing or walking reduction of stress to the abdominal incision
debridement - ANSWER removal of dead tissue from a wound
which diseases increase the patients risk for foot and nail problems? - ANSWER Diabetes PVD
