PN HESI SKIN INTEGRITY QUESTIONS AND ANSWERS ALREADY PASSED

PN HESI SKIN INTEGRITY QUESTIONS AND ANSWERS ALREADY PASSED The PN measures the length of time that the redness lasts. Which additional wound assessment technique is indicated? Apply light pressure to the area with the fingertips. How should the PN document this finding? Reactive hyperemia. Which areas are most important for the PN to observe for additional pressure ulcers? Heels and ankles What action should the PN implement? Identify these areas as sites where pressure damage has occurred. What etiology should the PN identify? Impaired motor function. Which goal will the PN include in Trey's plan of care? Client's skin will remain intact. To provide pressure relief at night, the PN reminds Trey to sleep in which position? Thirty-degree lateral inclined position. Upon learning that Trey has a pressure-reducing gel chair cushion for his wheelchair, which action should the PN take? Encourage him to continue to use this device in his wheelchair at all times. The PN shows Trey how to apply a transparent film dressing over the sacral area and advises him to follow which schedule for dressing changes? Once weekly. Which documentation best describes the drainage from Trey's wound? Purulent. Which intervention is important to reduce the effect of the diarrhea on Trey's skin? Apply a moisture-repellent ointment to intact skin areas. What action should the PN take? Assure the second nurse that written instructions in the client's room are effective and do not violate any client rights. Which protective equipment should the PN use when providing the prescribed wound care? Gloves, gown, goggles, and face mask. What equipment will the PN use to assess the length of the tract? Sterile cotton-tipped applicator. Which irrigation technique is best? Apply steady pressure using a 35-mL syringe and 19 gauge tip. How many mL of medication will the PN administer? 30 What is the total daily dosage that Trey will be receiving? (Enter numerical value only. If rounding is necessary, round to the whole number.) 1200 Who is the best member of the interdisciplinary team for the PN to collaborate with to resolve this discrepancy? Pharmacist Which technique should the PN use to mix the linezolid (ZYVOX)? Turn the bottle upside down 3 to 5 times. When pouring the suspension, the PN correctly uses which technique? Place the medication cup on a flat surface at eye level. The PN explains to Trey that this safety check reduces the risk for what potential problem? Anaphylactic reaction. Which class of medication should the PN expect to administer when prescribed? An antihistamime, such as diphenhydramine (Benadryl). Which diagnostic test should the PN review to determine if Trey is developing drug toxicity? Peak and trough. What is the best initial nursing action? Offer Trey the opportunity to discuss his feelings of anger and hopelessness. What is the best response by the PN? You are trying to cope with a lot of concerns right now. Considering Trey's developmental stage, the PN should plan to emphasize interaction with which group? Trey's girlfriend and his two best male friends from the college. It is most important to include this group in which aspect of Trey's overall care? Reviewing class notes and studying for exams. The PN encourages him to select which breakfast items to provide a good source of protein? Eggs and orange juice. What teaching should the PN reinforce? Hydrocolloid dressings should be continued over the ulcer.