A nurse is changing a dressing and providing wound care. Place the following activities in the correct order.
Wash hands thoroughly.
Put on latex gloves.
Slowly remove the soiled dressing.
Assess the drainage in the dressing
While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used.
Assess the client's current condition and vital signs.
If no acute injury, get help, and carefully assist the client back to bed.
Notify the client's health care provider (HCP) and family.
Document as required by the facility.
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
Inadequate protein intake
The nurse is examining a 6-week-old dark-skinned infant. There are large spots of deep blue pigmentation across the infant's buttocks. The nurse should identify this sign as characteristic of:
Mongolian spots.
A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema the client is on complete bed rest. To maintain skin integrity, what should the nurse do?
Turn the client every 1 to 2 hours
When teaching the diabetic client about foot care, the nurse should instruct the client to:
avoid going barefoot.
A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to:
consult a health care provider (HCP) about removing the corns.
A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?
Cool, pale fingers
The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first?
Cover the abdominal organs with sterile dressings moistened with sterile normal saline.
Which instructions should the nurse include in the teaching plan about skin care for the mother of a child with atopic dermatitis?
Use a mild soap followed by patting the skin to dry it.
While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next?
Continue to monitor the suture line, and document findings.
The nurse is assessing the client's umbilicus (see the accompanying image). The nurse should document the umbilicus as being:
midline.
An woman with a history of a left radical mastectomy is being admitted for abdominal surgery. The woman has a swollen left arm. The nurse should:
take the blood pressure only in the unaffected arm.
The nurse plans to teach a client who is receiving radiation therapy how to care for the skin at the radiation site. What should the nurse tell the client?
Keep the area covered when you go outdoors.
Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:
altered protective pressure sensation.
The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The nurse should first:
verify the prescription to use the restraint.
A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the
Stop the staple removal, cover the incision, and report the findings to the physician.
Which change in the integumentary system is associated with normal aging?
Subcutaneous fat and extracellular water decrease.
Which of the following is a priority nursing assessment of a reddened heel in a bed-ridden client?
Test for blanching to the affected area.
The client asks the nurse, "Why will the health care provider not tell me exactly how much of my leg he is going to take off? Do you not think I should know that?" On which information should the nurse base the response?
the adequacy of the blood supply to the tissues
Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?
The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.
Which client statement identifies a knowledge deficit about cast care?
I can pull out cast padding to scratch inside the cast.
For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing?
The granulation tissue is at the wound edges.
The nurse is documenting the assessment of a wound on a client's foot. Which of the following assessments would be included as subjective data?
Area around the wound is tender to touch.
After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which statement by a parent indicates successful teaching?
It's a fungal infection of the scalp.
After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at the greatest risk
Incontinence and right-sided hemiparesis
A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to:
reposition the client off the reddened skin and reassess in a few hours.
A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?
Turn him regularly.
An elderly client who is 5 feet, 4 inches (163 cm) and weighs 145 lb (65 kg) is admitted to the long-term care facility. The client sits for long periods in a wheelchair and has bowel and bladder incontinence. He can feed himself and has a fair appetite,
Incontinence
Sitting for long periods
Sedation
A nurse is caring for a client with a pressure ulcer. The nurse understands that the purpose of a hydrocolloid dressing application is to do which of the following?
Remove necrotic tissue by using enzymes
The nurse is providing an education seminar on skin care to clients and home care families. When discussing interventions, which areas have provided effective outcomes in preventing pressure ulcers? Select all that apply.
Clean the skin with warm water and a mild cleaning agent, then apply a moisturizer.
Turn and reposition the client every 1 to 2 hours unless contraindicated.
Use positioning devices to position the client and increase comfort.
A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment, the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist (ET). When gathering supplies for a s
The ulcer is superficial, like a blister.
Partial-thickness skin loss of the epidermis is evident.
When planning for risk management for clients who are at risk for development of pressure ulcers, the nurse should first:
identify at-risk clients on admission to the health care facility.
An older adult who is to be on bed rest has become incontinent of urine. To prevent pressure ulcers, the nurse should do which tasks? Select all that apply.
Institute a turning schedule.
Inspect the groin for wetness.
Have client wear incontinence briefs.