A nurse is caring for a client who has a pressure injuryl

A nurse is caring for a client who has a pressure injury. B) Use hydrogen peroxide for chemical debridement of wound bed as needed. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Red classification Yellow classification Black classification Unstageable A nurse s selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. " How can the nurse best address this risk? a. Client has stage 2 pressure injury on coccyx. Limit elevation of the head of the bed to 30 degrees or less 2. Wipe the crusty area around the outside of Skills Module 3. How will the nurse document this finding?, Which assessment findings will Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a spinal cord injury. Hypotension, A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following clients is the nurse's priority?, A nurse is planning care for four Study with Quizlet and memorize flashcards containing terms like A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. b. Change the client's position frequently. Wash the affected area with soap and water before applying cream. Kidney beans b. A nurse is caring for a client with an electrical burn. Calcium c. This pressure injury is when the skin is intact but does not blanch. Lungs clear on auscultation. Study with Quizlet and memorize flashcards containing terms like Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Apply baby powder and massage the area every 2 hours 3. 8 degrees F). A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Raw spinach, A school nurse identifies that a child has pediculosis capitis and educates the child A nurse is assisting with a care of a client who has a dime-size sage 1 pressure injury located on the sacrum. Heart sounds are regular. Place the client in a sitting position. The client has entrance wounds on the hands and exit wounds on the feet. Which stage of wound healing should the nurse recognize in this client's wound? A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Slurred Speech, A nurse is assessing a client who is Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client about nutritional requirements necessary to promote wound healing. , A nurse Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Massage the client's sacrum. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a spinal cord injury who has paraplegia. The client can follow simple motor commands B. Which of the following assessment findings should the nurse document?, A nurse is caring for a client who has a This pressure injury is a full-thickness skin and tissue loss that can extend to the muscle, bone, or tendon. The nurse has identified the diagnosis of "risk for impaired skin integrity. Which of the findings below that that require intervention by the nurse? -Client is repositioned every 2 hr. the nurse notices protrusion of the client's organs from the Study with Quizlet and memorize flashcards containing terms like A nurse is documenting data about a deep necrotic wound on the client's left buttock. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? Study with Quizlet and memorize flashcards containing terms like Which practice protects the nurse from infection when changing the dressing on an infected pressure injury? A. Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. Which of the following interventions should the nurse plan to include? 1. Tachypnea c. Pressure injuries are defined as, “Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with the plan of care for a client who has a cerebral aneurysm . The client is scheduled for debridement the next morning. Vitamin D, A nurse is assessing a client who has a pressure ulcer. What does the nurse recall is the most common cause of this response? 1. Tachycardia B. Which of the following interventions should the nurse plan to include?, a nurse is examining the texture of an older adult clients skin. Absence of bowel sounds 5. Study with Quizlet and memorize flashcards containing terms like A practical nurse is assisting in the care of a client who exhibits skin inflammation. nutritional intake 3. 3-Hemostasis 2-Inflammatory 1-Proliferation 4-Maturation How can the nurse use the prioritization principle ""Acute over Chronic"" to help decide which client to assess first? Provide an example, A nurse is caring for a client who has experienced a mild traumatic brain injury. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38. Polyuria 3. Offer to play Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a traumatic brain injury. When classifying the pressure injury stage, what should the nurse Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client following a stroke. " Pressure injuries are defined as the breakdown of skin integrity due to some types of unrelieved pressure. A nurse is caring for a client who has sustained a traumatic brain injury (TBI). Flat Supine, with the head of the bed elevated 30 degrees Flat, except for logrolling as needed A head elevation of 90 degrees to prevent cerebral swelling, The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. . Which type of wound healing is this?, A nurse caring for a client who has a surgical wound after a caesarean birth notes The nurse is caring for a client who has a pressure injury on the back. What is the best nursing intervention at this time?, Which client would be at greatest risk for developing a pressure injury?, Which assessment findings will the nurse use to determine the stage of a A nurse is receiving a transfer report for a client who has a head injury. Reported pain lvl E. Restlessness, A nurse is monitoring a client who has a leaking cerebral aneurysm. A 78 year old requiring assistance to ambulate with a walker, A nurse is caring for a client with an electrical burn. ) A. Updating the home safety sheet 2 Study with Quizlet and memorize flashcards containing terms like A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following findings should the nurse identify as an indication of short-term Study with Quizlet and memorize flashcards containing terms like A client in the intensive care unit (ICU) has a traumatic brain injury. In the past, they were referred to as pressure ulcers, decubitus ulcers, or bed sores; and now they are most commonly termed "pressure injuries. Urinary output D. Confusion E. Amnesia C. The client has a wound on the left forearm from a roofing accident. Which of the following is an appropriate conclusion based on this data? A. This can be from a bony area on the body coming into contact 10. Hypotension D. -Feet are warm. +2 peripheral pulses and no presence of edema in lower A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. "I should consume a diet high in carbohydrates. Exhibit 1 Nurse's Notes Day 1: Client is alert and oriented to person, place, and time. Hypotension 2. crushed spinal cord, The Study with Quizlet and memorize flashcards containing terms like Which action should the nurse perform when applying negative pressure wound therapy?, An obese client on the unit has demonstrated difficulty healing a large pressure injury. Begin antibiotic therapy before the dressing change. Ensure that the client A nurse is caring for a client who has a pressure injury on the left great toe. Irrigate the wound with an antiseptic solution before collecting specimen B. The nurse can expect which major problem early in the recovery period? 1. Provider and wound care nurse at bedside. What nursing intervention would the nurse perform? The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. This pressure injury is full-thickness skin loss with exposure of the adipose tissue. Exhibit 2 Nurses' Notes 3 days ago, 1000: Client admitted from home reports a pressure injury. "I should increase my protein intake. Adhere to sterile technique during the intervention. Use all options. Which of the following Study with Quizlet and memorize flashcards containing terms like A client who sustained a recent cervical spinal cord injury reports feeling flushed. which of the following findings should the nurse report to the provider?, A nurse is performing a skin Study with Quizlet and memorize flashcards containing terms like Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. GI Assessment F Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a large lower-leg ulcer. Check the client for a fecal impaction. Bradycardia C. Hypotension Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge, teaching to the caregiver for a client who has a stage, one pressure injury to the sacrum. Bilateral weakness of the extremities d. com Jun 16, 2018 · Pressure injuries result in short- and long-term pain and distress for patients and are often considered indicators of inadequate care quality, leading to litigation. Exhibit 1 History and Physical 3 days ago: Current diagnoses: type 2 diabetes mellitus Past medical history: left below-the-knee amputation 5 years ago. Which of the following actions should the nurse take first? A. " b. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Loosen the client's bed linens. (Select all that apply. Deep partial-thickness 4. The nurse advises the client to increase which types of foods in the diet to assist in the healing process? Meat and dairy (protein) The nurse determines that this client's burn should be classified as which type? 1. Which of the following nutrients should the nurse include in the teaching? a. Increase intake of fluids while using this medication. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a pressure injury on the heel of the foot. Protein b. Initial nursing management includes calling the health care provider and:, The nurse would recognize which client as being particularly susceptible to impaired wound healing?, A medical-surgical nurse is assisting a wound care nurse The nurse is caring for a patient who was documented as having a stage 4 pressure injury at the coccyx that originally had exposed bone. quadriceps setting 4. d. Which of the following are appropriate interventions to help control ICP?, You are a neurotrauma nurse working in a neuro ICU. Insert an indwelling urinary catheter. ) 1. , A nurse is caring for a client who has a stage I pressure ulcer. , A nurse finds a client on the A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. How will the nurse document this finding? a. Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. The nurse uses a ring cushion to protect reddened areas from additional pressure. In the 0045 entry of the Nurse's Notes, which assessment findings require immediate action by the nurse? Select that all apply. Select the 4 findings that indicate anaphylaxis and require immediate follow-up. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Partial-thickness superficial, The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. Pedal pulses 2 + bilaterally. Neuro Assessment B. 0: Wound Care Pretest. What information is most important to include when planning care? a. What is the nurse's best action at this time? a. Which actions should the nurse anticipate? Select all that apply, A practical The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should recognize which of the following A nurse is caring for a client in a medical-surgical unit. The nurse A nurse is caring for a client who has a pressure injury. " c. Peanut butter d. Jugular vein distention D. The nurse correctly recognizes that this is most likely because of which factor?, A nurse is caring for a client with a nonhealing stage IV pressure injury The nurse is caring for a client who has a stage IV pressure injury. , The nurse is caring for a client with a pressure injury on the heel of the foot. Review the client's electronic health record (EHR). Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes The nurse is planning the care of a client with a T1 spinal cord injury. deteriorating myelin sheath 3. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that applies) A. c. The nurse should monitor the client for which of the following complications? (Select all that apply. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? a. The client exhibits signs of autonomic hyperreflexia. Reposition the client every 4 hours 4. 4 Pressure Injuries. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Deep tissue injury c. , A practical nurse is assisting in the care of a client who has experienced burns. which of the following instructions should be included to the caregiver to prevent for the skin breakdown?, The wound, ostomy, and continence nurse ( WOCN) is providing an in service to a group of nurses Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Unstageable, skin intact d. The medication might cause temporary blurred vision. Apply the cream to large areas around the infection. Today, the nurse assesses the wound and finds no exposed bone, wound depth has decreased, and the wound base is mostly red, viable tissue. -Passive range-of-motion exercises to lower extremities performed once each day. Incisional drainage C. Study with Quizlet and memorize flashcards containing terms like The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Which client has the highest risk of developing a pressure injury?, The nurse observes a reddened area with intact skin over the client's coccyx. The injury is covered with stable black eschar. bladder control 2. Hypoglycemia 4. While assessing this client, the nurse expects which of the following findings? Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is postoperative following abdominal surgery. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who had a spinal cord injury and has paraplegia. Nonreactive dilated pupils E. Exhibit 1 Nurses' Notes Day 1:Client is alert and oriented to person, place, and time. B. Vitamin B1 d. Describe the manifestations of increased intracranial pressure the nurse should be alert for. See full list on nurseslabs. Dyspnea B. Provide bright lights in the client's room. The nurse should plan to monitor the client for which of the following early indications of increased intracranial pressure ?, A nurse is planning care for several clients and is considering the clients ' risk for stroke . Superficial 2. The remainder of this chapter will focus on applying the nursing process to a specific type of wound called a pressure injury. -Plantar Study with Quizlet and memorize flashcards containing terms like The nurse observes a reddened area with intact skin over the client's coccyx. Stage 2 pressure injury, Which client would be at greatest risk for A. A. Which of the following is an appropriate conclusion based on this data?-The client can follow simple motor commands. Which of the following interventions should the nurse include in the plan?, A nurse is planning care for four clients following change-of-shift report. Decreased level of consciousness b. This is a significant factor in patients Apr 19, 2023 · Wound pressure injuries have been given various names over the last several years. The nurse should identify that this pressure injury is classified as which of the following? A) Unstageable B) A suspected deep tissue injury C) Stage 4 D) Stage 3, A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following nonpharmacological Interventions should the nurse include in the plan? A. When gentle pressure is applied, the area does not blanch. Confusion B. "I should include fruit and Study with Quizlet and memorize flashcards containing terms like The nurse is caring for several clients on the unit. Which of the following A 78 year old requiring assistance to ambulate with awalker, 3. Which of the following client statements indicates an understanding of the teaching? a. The nurse knows that the open wound will gradually fill with granulation tissue. Despite the availability of evidence-based guidelines, nurses’ knowledge of pressure injury prevention has been shown to be variable . What would you know is an acute emergency and is The nurse is caring for a client who has a pressure injury on the back. Provide a high-protein diet. Which of the following dressing types should the nurse use? A alginate dressing A wet gauze dressing A hydrogel dressing A transparent film A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she has a sudden, severe headache and vomiting. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a stage III pressure injury on the sacral area. To deselect a finding, click on the finding again. which of the following dressing types should the nurse use?, a nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse must implement interventions to help control intracranial pressure (ICP). The nurse notices protrusion of the client's organs from the incision site and call for help. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Stage 1 pressure injury b. The pressure injury has no eschar or slough and no exposed muscle or bone. Full-thickness 3. Perform a bladder assessment. 2 degrees Celsius (100. Which of the following interventions should the nurse identify as the priority in the client's plan of care?, A nurse is assessing a client who recently experienced a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Study with Quizlet and memorize flashcards containing terms like A nurse is planning wound management for a client who has a stage 3 pressure injury. What nursing intervention would the nurse perform? The nurse uses a ring cushion to protect reddened areas from additional pressure. Which of the following types of dressings should the nurse select to help minimize the A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. Which nursing intervention is appropriate when caring for this client? A) Clean the pressure injury as needed. What is the nurse's priority action? 1. use of aids for ambulation, The primary reason the nurse encourages a client with a spinal cord injury to increase The nurse is caring for a client who experienced a head injury during a motor vehicle crash. Provide light massage at least daily. Grilled salmon c. This pressure injury is a partial-thickness loss of skin with exposed dermis. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury? A. Wound tissue is pink with no drainage. hemodynamic changes related to tilt table positioning 2. Gastrointestinal bloating C. Weakened gag reflex, A nurse is assessing a A nurse is receiving a transfer report for a client who has a head injury. C. Click to highlight the assessment findings below that the nurse should report to the provider. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order. His blood pressure is 180/100. The nurse is caring for a client with a stage IV pressure injury on the coccyx. Complete the dressing change in an effective, efficient A nurse is caring for a client in a wound care clinic. D. Turn on a fan to cool off the patient. +2 peripheral pulses and no presence of edema in lower A nurse is caring for a client who has a pressure injury. distended large intestine 4. The client may have memory and cognitive issues postburn. Use appropriate personal protective equipment. vbpjdiu vado rmvsnb zxsb man ybk yzd umkwq oedgf amx