- Study guides, Class notes & Summaries

the ap places the client in high fowlers position - correct answer A nurse is observing an assistive personnel care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity? dermatitis - correct answer A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity? what is dermatitis - correct answer inflammation of the ski...

Epidermis - correct answer e. Top layer of the skin Dermis - correct answer f. Inner layer of the skin that provides tensile strength and mechanical support Collagen - correct answer a. Tough, fibrous protein Pressure ulcer - correct answer b. Localized injury to the skin and underlying tissue over a body prominence Blanching - correct answer d. Normal red tones of light-skinned patients are absent Darkly pigmented skin - correct answer c. Does ...

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a) Document the findings and continue to monitor the patient. b) Administer antipyretics, as ordered. c) Increase the frequency of assessment to every hour and notify the patient's primary care provider. d) Increase the frequency of wound...

1. What does a Braden Score of 14 indicate to the nurse? a. High risk for the development of pressure ulcers b. Low risk for the development of pressure ulcers c .The need for a special mattress d. The presence of a pressure ulcer - correct answer ANS: A High risk for the development of pressure ulcers The lower the score the higher the risk of pressure ulcer formation. While research continues as to where the cut off for risk should be, it is generally accepted that a Braden of 16...

the nurse observes that the reddish area is round and is directly over the client's sacrum. the skin in intact. 1. in addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? - correct answer - apply light pressure to the area with the fingertips (the RN applies light pressure with the fingertips to assess for blanching. this is a normal response in light-skinned clients, which indicates there is no tissue perfusion impairmen...

Collagen - correct answer tough, fibrous protein pressure ulcer - correct answer Inflammation, sore, or ulcer in the underlying tissue over a bony prominence as a result of pressure with shear or friction tissue ischemia - correct answer point at which tissues receive insufficient oxygen and perfusion blanching - correct answer occurs when the normal red tones of the light-skinned patient are absent blanchable hyperemia - correct answer redness of the sk...

What are the two layers of the skin? - correct answer Epidermis Dermis Skin issues related to aging - correct answer Decreased elasticity Decreased collagen Thinning of muscles and tissues Medical conditions Polypharmacy Slower epithelialization and healing Decreased padding over bony prominences Prevention of skin-related issues in aging - correct answer Remove adhesive tape gently Use repositioning devices Assess bony prominences and risk areas Assess effects...

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection - correct answer 3 The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the clients bowel resection. For which category of wound shoul...

Hypoxemia - correct answer insufficient level of oxygen in the arterial blood (<80mmHg) requires an ABG to diagnose. Hypoxia - correct answer Decreased delivery of oxygen to the tissues Debridement: - correct answer Removal of dead, damaged, or infected tissue Emollient - correct answer gents that soften skin or treat dry skin Granulation - correct answer Connective tissue that forms on the surface of a healing Epithelium - correct answer Tis...

Pressure ulcers form primarily as a result of? KEY WORD PRIMARY - correct answer tissue ischemia Risk Factors for Pressure Ulcers? - correct answer Immobility, Inadequate nutrition, Fecal and urinary incontinence, Decreased mental status, Diminished sensation, Excessive body heat, advanced age, poor lifting and transferring techniques, incorrect positioning, hard support surfaces, incorrect application of pressure relieving devices, friction and shearing. The nurse notes ...