A nurse is preparing to apply a dressing for a client who has a stage 2

A nurse is preparing to apply a dressing for a client who has a stage 2. The wound has a gauze dressing covering the area. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an assistive personnel (AP). Stage 2 pressure injury, Which client would be at greatest risk for Study with Quizlet and memorize flashcards containing terms like A nurse is assisting in the care of a client who is being placed on transmission-based precautions. Change the transparent dressing on a client who has a stage 2 pressure ulcer B. Deep tissue injury c. If you plan to touch the dressing, donne non-sterile gloves to protect yourself from exposure to BBF. Which of the following instructions should the nurse include in the teaching The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. "Encourage meals at least three times daily. C) Replace the gauze with A nurse is performing sterile wound irrigation for an assigned client. When gentle pressure is applied, the area does not blanch. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. "Provide 1. A nurse has demonstrated the proper cleaning and dressing change techniques for a client's postoperative wound. D. -Apply a transparent dressing over the incision site. A student nurse enters the client's room and notices the nurse preparing the sterile field. The nurse has the client then demonstrate the proper technique and repeat when to change the dressing and why. Use non-sterile gloves to remove the old dressing. Verbal communication consists of which A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. The stratum The nurse should place a sterile, saline-soaked dressing over the client's wound to prevent the dressing from adhering to the tissue and protect the organs until the client is taken back to surgery. Full-thickness skin loss 3. Keep liquids at the bedside. Indirect contact, A nurse is caring for a client who is on contact precautions Study with Quizlet and memorize flashcards containing terms like Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. 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 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. The injury is covered with stable black eschar. Obtain the prescribed irrigation solution b. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. There is a notation that states there is an absence of the stratum corneum. Which of the following actions is the nurse's priority? a. Instruct the client about home disposal of contaminated dressings. B. Click the card to flip 👆. Study with Quizlet and memorize flashcards containing terms like A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Exposed bone, tendon, or Study with Quizlet and memorize flashcards containing terms like A client has an odorous, purulent wound. Eating a sandwich D. b) Put on clean gloves and Sep 25, 2023 · For a client with a Stage 2 pressure injury, it is generally recommended for a nurse to use a Hydrocolloid dressing. "Keeping the room warm will help them breathe easier. What is the priority nursing A nurse is caring for a client who has a stage II pressure ulcer. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure? Study with Quizlet and memorize flashcards containing terms like While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. Which type of wound healing is this?, A nurse caring for a client who has a surgical wound after a caesarean birth notes A nurse is caring for a client who is in early stage renal failure and has a prescription for the infusion of IV fluids. com A guide to the form and function of wound dressings by composition is ofered to aid clinicians in appropriate dressing selection to match the characteristics of the wound for optimal healing outcomes. Obtain the prescribed irrigation solution B. Which of the following actions by the new graduate indicates a need for further education about pressure injury care? a. 3. Intact skin 2. Perform hand hygiene. Airborne D. Skin surrounding Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a newly licensed about hand hygiene. 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 A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? A. Which of the following tasks should the nurse direct the AP to perform first? A. Bring a pitcher of fresh water to a client who has just had a lumbar puncture. c) Place soiled dressings directly in the trash. Use hot water when washing The nurse is planning to perform a dressing change for a client with a stage three pressure ulcer. "Help them onto their left side if they are experiencing nausea. Droplet C. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. Which of the following actions should the nurse take?, A nurse is using an open irrigation technique to irrigate a client's Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. c. The nurse knows that the open wound will gradually fill with granulation tissue. How will the nurse document this finding? a. - Hyperlipidemia - Diabetes Mellitus - Medication History - Cholesterol Level - Prealbumin level, A nurse is preparing to assist with irrigating a wound for a client 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. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis C) Inflammatory phase D) Maturation phase, Upon responding to the Study with Quizlet and memorize flashcards containing terms like The nurse prepares to irrigate a wound and apply antiseptic. Change the transparent dressing on a client who has a stage 2 pressure ulcer 2. Calcium alginate d. Proteolytic enzyme Study with Quizlet and memorize flashcards containing terms like An older client is transferred to the nursing unit following a graft to a stage 4 pressure injury. b. ) A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which statement indicates the need for Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with teaching a newly licensed nurse about infectious agents. What precaution will the nurse take while performing this dressing change? a) Apply a mask. Which of the following wound dressing should the nurse apply to the ulcer? a. Heart sounds are regular. Buttoning a shirt B. Sterile water is often the solution of choice when irrigating wounds. Transport a client to the radiology department for a routine chest X-ray. Exhibit 1 Nurse's Notes Day 1: Client is alert and oriented to person, place, and time. Uses a hydrocolloid dressing (DuoDerm) to cover the wound b. In planning client rounds, which client should the nurse assess first? 1. " B. The tissue easily bleeds when the nurse performs wound care. Biofeedback B. Acupuncture The nurse is preparing to complete a dressing change on a client with a Stage 2 pressure ulcer. Place a waterproof pad under the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has acute renal failure. a) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. Which stage of wound healing should the nurse recognize in this client's wound? A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The client's position should be changed a minimum of every 2 hours. Which of the following IV fluids does the nurse anticipate a prescription for and why? Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a stage III pressure ulcer on the heel. Check the client's pain level D. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. What is the nurse's best action? Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple Study with Quizlet and memorize flashcards containing terms like A nurse is learning about communication concepts and techniques. The nurse should use warm water to wash hands to decrease the risk of removing protective oils from skin. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing the client's medical record. A nurse is providing discharge teaching to a client about self-administering heparin. Vitamin D, A nurse is caring for a client who has a large lower-leg ulcer. A client requiring daily dressing changes of a recent surgical incision 3. Which of the following types of dressing should the nurse use? Hydrocolloid (Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. Alginate. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing B) Increase the frequency of the dressing changes. Hydrocolloid dressings encourage a moist environment that is advantageous for wound healing, and provide protection against infection. Apply non-sterile gloves: 2. When the solution from the wound turns light pink Study with Quizlet and memorize flashcards containing terms like A client is admitted with a stage four pressure injury that has a black, hardened surface (eschar) that is stable. " D. Which of the following types of dressing should the nurse Study with Quizlet and memorize flashcards containing terms like Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. Schedule a follow-up visit by a home health nurse for dressing changes. A. Which of the following actions should the nurse plan to take when caring for this client? Select all that apply, A nurse is assisting with caring for a female client who has a newly placed ileostomy, A nurse is caring for a client A nurse is caring for a client in a wound care clinic. Make sure the pillow has a plastic Study with Quizlet and memorize flashcards containing terms like Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a client's wound? Select all that apply. 1. Unstageable, skin intact d. Perform hand hygiene: 3. See full list on nurseslabs. A postoperative client preparing for discharge with a new medication 2. The stratum corneum provides insulation for temperature regulation. After checking the physician's order, which actions should the nurse take next? Perform hand washing and check the client's identity. Study with Quizlet and memorize flashcards containing terms like The nurse in the ED is caring for a client who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. Documenting the characteristics of the wound D. How does the nurse best support this client? Changes the dressing frequently Encourages a diet high in protein Suggests whirlpool therapy Places room deodorizers in the room, The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus Study with Quizlet and memorize flashcards containing terms like A nurse is admitting a new client. Which of the following instructions should the nurse include? A. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. Which dressing is best for the nurse to use first?, What is the rationale for using the nursing process in planning care for clients?, A client with Raynaud's phenomenon asks the nurse about using biofeedback for Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. B) Pack a small piece of cotton deep into the client's ear canal. In addition, incontinent care Study with Quizlet and memorize flashcards containing terms like The nurse is assigned to care for four clients. A nursing assistant enters the client's room and tells the nurse that a physician has telephoned and has asked to speak to the nurse. Securing Velcro shoes E. Which of the following actions should the nurse take while performing medication reconciliation?, A nurse is preparing to administer enoxaparin subcutaneously to a client. -Apply a skin protectant to the skin around the incision. A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hours post-op. , What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing?, A nurse is cleaning the wound of a client who has been injured The nurse has removed the sutures and is now planning to apply wound closure strips. Washing the left arm C. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Direct contact B. Hydrocolloid dressing promote healing in stage 2 pressure injuries by creating a moist wound bed. A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Study with Quizlet and memorize flashcards containing terms like A client experiencing temporary functional ability of the right arm and hand will need assistance with which activities of daily living (ADLs) while hospitalized on a medical-surgical unit? Select all that apply. The nurse should recognize that which of the following statements by the clients partner The charge nurse observes a new graduate nurse performing a dressing change on a client with a stage 2 left heel pressure injury. Which of the following assessments provides the most accurate measure of client's fluid status?, A nurse is teaching a client who has lower extremity weakness how to use a 4-point crutch gait. The nurse will follow which guideline for performing this procedure? If the wound is closed, clean technique may be used instead of sterile technique. . After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. Provide the client with a diet high in vitamin C, zinc, and protein. Take an arterial blood gas specimen to the laboratory. C. Hydrocolloid b. Which statement by the nurse is correct about intrapersonal communication?, In the communication process, what does the nurse understand the "channel" to be?, Verbal communication is a key process for caring for clients. 2. Administer prescribed oral pain medication Question: 1 of 60 CORRECT Time Elapsed: 00:01:20 Pause Remaining: 08:20:00 PAUSE A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Don personal protective equipment c. Washing clothes, The Study with Quizlet and memorize flashcards containing terms like A nurse is removing the staples from a client's surgical incision, as ordered. A client scheduled for a chest x-ray after insertion of a 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. 4. IV dressing dry and intact. Which of the following explains why this is a concern? 1. The client has a wound on the left forearm from a roofing accident. b) Don disposable gloves. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which is the priority nursing action? 1. Alginate- treat stage 3 and 4 pressure injuries to absorb drainage. Which nursing interventions would be helpful in managing this symptom? Select all that apply. The nurse is caring for a client who is to have a sterile dressing change to a wound. Feverfew D. A) Press gently on the tragus of the client's ear. Collagen c. Assess dressing for signs of shadowing / bleeding, type and size of dressing used. Which of the following foods should the nurse . Calcium C. Protein B. Lungs clear on auscultation. which of the following types of dressing should the nurse use Your solution’s ready to go! Enhanced with AI, our expert help has broken down your problem into an easy-to-learn solution you can count on. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. Transparent. During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. The nurse notices protrusion of the client's organs from the incision site and call for help. " C. Stage 1 pressure injury b. Turn and reposition the client every 2 hours. 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 A nurse is caring for a client who has a pressure injury. Study with Quizlet and memorize flashcards containing terms like The nurse observes a reddened area with intact skin over the client's coccyx. IV fluid infusing well. The nurse should inform the client that this condition is a contraindication for which of the following therapies A. IV site without redness or swelling. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The nurse should initially perform which action? A. What should the nurse do before applying the strips?-Apply a sterile gauze sponge over the incision site. Assess current dressing. Which of the following nutrients should the nurse include in the teaching? A. Which of the following types of dressing should the nurse use?, A nurse is caring for a client who has a terminal illness and is at the end of life. a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Gauze. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who started a prescription for phenytoin 3 weeks ago. -Apply a skin protectant to the incision site. Place a towel over the pillowcase. +2 peripheral pulses and no presence of edema in lower A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Use alcohol-based hand sanitizers on hands for at least 10 seconds. By allowing the client to demonstrate learning, which type of educational learning has been practiced? 1. Which of the following types of dressing should the nurse use? A. 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. Day 2: IV site edematous. d) Use sterile technique. Clean the ulcer with hydrogen peroxide and leave it open to the air. When preparing to irrigate the wound, which of the following actions should the nurse take first? a. 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. Vitamin B1 D. Check the client's pain level d. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. Place a waterproof pad under the 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. Which of the following types of dressing should the nurse use 8. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing?, The nurse reinforces home care instructions with a client diagnosed with impetigo. Cover the ulcer with an occlusive transparent dressing. Hand hygiene reduces risk of spread of microorganisms. Don personal protective equipment C. Which of the following assessment findings should the nurse identify as an indication of a hypersensitivity reaction to the phenytoin? a) enlargement of the cervical lymph nodes b) diarrhea c) ringing in the ears d) alopecia, A nurse is caring for Study with Quizlet and memorize flashcards containing terms like A nurse is reinforcing teaching with the caregiver of a client who is near death. C) Move the client's auricle down and back toward her head. Which of the following instructions should the nurse provide? A. Cognitive 2 Study with Quizlet and memorize flashcards containing terms like use pillows to maintain a side-lying position as needed (Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. Hydrocolloid. Client has stage 2 pressure injury on coccyx. Bring a pitcher of fresh water to a client Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a stage III pressure ulcer on the heel. Wound tissue is pink with no drainage. Aloe C. Gather all the necessary equipment B. What is the correct name of this wound?, During a dressing change, the nurse assesses protrusion of intestines through an Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Answer: D. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. djkmh pqzv fuy jssy awuasw hvtidwxp xyuqtk obfrsk janm dobvtp