A nurse is preparing to apply a dressing for a client. -During this dressing change. -On day the surgery occurs. The primary care provider has ordered culture of the wound. Indirect contact, A nurse is caring for a client who is on contact precautions Study with Quizlet and memorize flashcards containing terms like When caring for a client with burns, a nurse should change the wound dressing at least once every: a. Control personal thoughts about the client. The nurse prepares to irrigate the wound and apply a new dressing. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A. 5 for commonly used wound dressings and associated nursing Ensure proper lighting to allow for good visibility to assess the wound. Use an aqueous solution of aluminum acetate (Burow's solution) to wet the dressing. , The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. , Avoid assumptions about the client. Transparent D. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? A. 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. Disorientation to time only 2. Which of the following findings should the nurse identify is infiltration of the IV infusion site?, A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to irrigate a client's wound which of the following actions should the nurse take?, A nurse is caring a client who is hospitalized and has a new tracheostomy. Have the client sit in a chair dangling before wrapping. dehiscence c. Which of the following actions of sucralfate should the nurse include in the teaching?, A nurse is caring for a female older adult on a med-surge unit. Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing the client's medical record. What action should the nurse prioritize? a. The nurse determines that a client would benefit from the use of a walker to ambulate. Have the client lie down for 15 minutes before wrapping. -The second postoperative day. The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. Which tasks cannot be delegated to Study with Quizlet and memorize flashcards containing terms like "Let me show you how I will take my blood pressure at home each day. The presence of a Study with Quizlet and memorize flashcards containing terms like The nurse is teaching a client the reasons for use of negative pressure wound therapy (NPWT). Which protective interventions would the nurse use to perform this procedure? Study with Quizlet and memorize flashcards containing terms like The nurse is caring of a client who has a peripherally inserted center catheter (PICC) in place to receive antibiotics. - 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 The nurse is caring for a client who is having a thoracentesis. 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. Record dressing change as per hospital policy. Apply the hydrocolloid dressing over a normal saline-soaked Study with Quizlet and memorize flashcards containing terms like A nurse is preparing an operating room theatre for a surgical procedure. Which finding indicates adequate fluid resuscitation? 1. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. week, Which instructions should a nurse provide a client with burns who has undergone a skin grafting? Select all that apply a. Which of the following instructions should the nurse include in the teaching Study with Quizlet and memorize flashcards containing terms like Which nursing action is a component of medical asepsis? handwashing after removing gloves insertion of an indwelling urinary catheter insertion of an intravenous catheter drawing blood from a central line, Which practice is a correct application of infection control practices? A nurse performs hand washing each time the nurse Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who started a prescription for phenytoin 3 weeks ago. Click the card to flip 👆. Which action should the nurse perform in obtaining a wound culture? A) Cleanse the wound after obtaining the wound culture. For which reason would the nurse use surgical asepsis? A. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure? The home health nurse is preparing a plan of care for the client and should appropriately document which intervention? A. Which action should the nurse perform, keeping in mind the importance of asepsis and client comfort?, The nurse begins a task and then realizes that personal protective equipment (PPE) is Study with Quizlet and memorize flashcards containing terms like The nurse is evaluating fluid resuscitation attempts in the burn client. Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with teaching a newly licensed nurse about infectious agents. A mole with an asymmetrical appearance D. Document the wound appearance, if the staples are intact, if the incision is well-approximated. Which term best describes this complication? a. Hydrocolloid dressing promote healing in stage 2 pressure injuries by creating a moist wound bed. Start from the top of the incision A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following actions should the nurse take when performing tracheostomy care for the client?, A nurse is teaching a middle-aged female client The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Direct contact B. What is the nurse's first action? - exerting equal, but not excessive, tension with each turn of the bandage - wrapping distally to proximally - elevating and supporting the stump - keeping the bandage free of gaps between turn Study with Quizlet and memorize flashcards containing terms like The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Droplet C. After reviewing the image, what is the most important step for the nurse to take?, A nurse is providing care to several clients. Pull from the left to right across the abdomen. chelitis d. Enclosed hemostat clamps D. Complete the following sentence by using the lists of Study with Quizlet and memorize flashcards containing terms like A client has an odorous, purulent wound. Perform hand hygiene. Which protective interventions should the nurse use to perform this procedure? Select all that apply. Occlusive dressing, A nurse is caring for a client who has a chest tube Study with Quizlet and memorize flashcards containing terms like The nurse is collecting a blood sample from a central venous access device (CVAD). Study with Quizlet and memorize flashcards containing terms like The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal lower abdominal incision. ", The client is engaged and alert. Urine output of 30 mL over the past 2 hours, The nurse has provided instructions to a client with Study with Quizlet and memorize flashcards containing terms like Which event would require a nurse to complete and file an incident report? 1. ) A. day c. B. Ensure proper body mechanics for yourself and create a comfortable position for the patient. Which of the following items should be available in the client's room? (Select all that apply. which of the following types of dressing should the nurse Here’s the best way to solve it. B) Stroke the culture swab on surrounding 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. lift it proximally, and then work distally while stabilizing the catheter with an antimicrobial swab B. Change the hydrocolloid dressing every 3 to 5 days. ), A nurse is preparing for a teaching session with a client. ) Pre-medicate the client with an analgesic. Reduces the risk for growing opportunistic microorganisms The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply. Place a dry dressing in the wound. When a visitor Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has acute renal failure. Indwelling urinary catheter E. What should the nurse do before applying the strips?-Apply a sterile gauze sponge over the incision site. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. Oxygen B. What type of dressing should the nurse apply over the client's The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. a comedone, Which type of cardiomyopathy are characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic Study with Quizlet and memorize flashcards containing terms like A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. three days b. Protects self from microorganisms in the wound D. Which of the following actions should the nurse take while performing medication The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. Which personal protective equipment will the nurse use when providing care to the client?, The nurse prepares to administer medications to a client. Removing respirator after leaving client's room B. Alginate B. It promotes wound healing and wound closure. Contact precautions are prescribed for the client. c. a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Continue with the dressing change. Perform hand hygiene: 3. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?, When explaining the inflammatory response to nursing students, the instructor describes a series of events. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? a. The nurse is preparing to change a client's sterile dressing. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to care for a client following chest tube placement. Heart rate of 95 beats/minute 3. Transparent. A client has a seizure. Following the procedure, the nurse monitors for complications. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Airborne D. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Cover the wet packing with a dry sterile dressing. The nurse should recognize that which of the following statements by the clients partner A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. Thoracentesis is commonly used to treat pleural effusion. Collaborate with another nurse to develop teaching strategies. Apply non-sterile gloves: 2. Gauze C. Assess current dressing. Study with Quizlet and memorize flashcards containing terms like In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. Apply warm compresses to the ankle before wrapping. lift it distally, and then work proximally to the insertion site while Study with Quizlet and memorize flashcards containing terms like a nurse manager is reviewing ethical principles with the nursing staff. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. Alginate. See Table 20. As the nurse prepares to change the dressing of the PICC, how should the nurse position the client?, The nurse is preparing to change the dressing for a client with a peripherally inserted central catheter (PICC Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. ), A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change The nurse has removed the sutures and is now planning to apply wound closure strips. two hours d. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints When changing the dressing of a central venous access device (CVAD), how should the nurse remove the old dressing? A. Keeps the area free of microorganisms B. Premedicate, if indicated, to ensure patient’s comfort prior to and during the procedure. fistula b. a carbuncle c. , When 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. Study with Quizlet and memorize flashcards containing terms like A nurse is providing teaching to a client who has peptic ulcer disease and is to start a new prescription for sucralfate. Assess dressing for signs of shadowing / bleeding, type and size of dressing used. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure? a. Hydrocolloid, A nurse is admitting a new client. Solution Study with Quizlet and memorize flashcards containing terms like A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply. 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 Study with Quizlet and memorize flashcards containing terms like When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?, The nurse is assigning care to the unlicensed assistive personnel (UAP) for a client with a nasogastric tube with intermittent suction after gastric surgery. 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 preparing to apply a dressing for a client who has stage 2 pressure injury. The nurse understands that this type of testing is beneficial for which reason?, A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to apply an ace bandage to a client's left ankle after the client has been walking. Donning respirator inside of client's room, A nurse is caring for a client who is diagnosed Study with Quizlet and memorize flashcards containing terms like A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. A specially trained wound care nurse should be consulted, when possible, for appropriate selection of dressings for chronic wounds. Place the Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Notify the healthcare provider. Hand hygiene reduces risk of spread of microorganisms. Wound dressings should be selected based on the type of the wound, the cause of the wound, and the characteristics of the wound. It results in a The practical nurse (PN) is preparing to change the abdominal dressing for a client who had abdominal surgery yesterday. Hydrocolloid. Removing gown after leaving client's room C. , A client returns from the recovery room following an abdominal surgical procedure. What should the nurse include in the teaching? Select all that apply It allows for earlier ambulation after surgery. 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 After discussing the use of restraints with a client and family, a physician has written a prescription for wrist restraints to be applied to a client. Begin Study with Quizlet and memorize flashcards containing terms like What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? transparent film hydrocolloid dressing hydrogel alginate, The nurse is preparing to insert an IV for a client with dehydration. Confines microorganisms to the surgical site 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 The nurse is preparing to complete a dressing change on a client with a Stage 2 pressure ulcer. What should the nurse do next? Ask the client to bear down. increase the intake of Pack wound cavities densely with dressing material to promote tissue healing. a furuncle b. The health care provider (HCP) will prepare the skin, inject The nurse is caring for a client who is to have a sterile dressing change to a wound. +1 palpable peripheral pulses 4. 1. Which dressing supply will the nurse gather to take in the client Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to perform a peripherally inserted central-line catheter (PICC) line dressing change on a client, but notices that the catheter appears to be longer than before. Gauze. -Apply a transparent dressing over the incision site. Chart the time, place of wound, size, drainage and amount, type of cleaning solution, and dressing applied. Change the hydrocolloid dressing daily. -Apply a skin protectant to the skin around the incision. 2. A student nurse enters the client's room and notices the nurse preparing the sterile field. "I'll wrap the old dressing in a paper bag and put it in the trash" b. ) A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which action by the nurse would increase the risk for infection? checking that the sterile dressing packages are intact before opening describing each step verbally to the client before performing the dressing change ensuring that the surface where the sterile field will be set up is dry applying a new dressing with the gloves that Study with Quizlet and memorize flashcards containing terms like Which action is the best example of a nurse donning/removing protective equipment properly? A. Which Study with Quizlet and memorize flashcards containing terms like A nurse is preparing for a teaching session with a client. New appearance of Petechiae C. When should the PN reinforce teaching about the client's dressing change?-The morning of the discharge. C. What should the nurse do first?, When The nurse is preparing to change a client's dressing. If you plan to touch the dressing, donne non-sterile gloves to protect yourself from exposure to BBF. This is an example of which step in discharge planning?, In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. pull it up from the top to the bottom, applying pressure to the catheter with a gauze pad C. Donning gown after entering client's room D. What method should the PN use to remove the tape from the dressing? 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. Apply the hydrocolloid dressing over a dry, sterile dressing. restrict movement for a period of time b. Study with Quizlet and memorize flashcards containing terms like When performing a skin assessment, the nurse notes a localized skin infection of a single hair follicle. 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 A nurse who has finished cleansing and dressing the wound of a young client now needs to change the dressings of a client in the burn unit. Which of the following actions should the nurse take to provide the client with unbiased . Which example does the nurse manager provide to explain the concept of fidelity, the nurse is demonstrating client advocacy in which of these situations SATA a) Helping a client bathe b) Changing a client's abdominal dressing c) Including the client in the 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. 4. Which of the following client data are acceptable for use as 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. D. The nurse is using a dosage example of two tenths of a milligram. evisceration, The nurse has received an order to apply a saline-moistened dressing to a client's wound Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to apply a prescription ointment to the client's wound. and more. A lesion with uniform pigmentation B. How much blood should the nurse collect in the discard tube?, The nurse is collecting a blood sample from a client's central venous access device (CVAD) and notices that the flow stops when drawing the blood. d. Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis? Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. The nurse documents the presence of: a. A nurse is preparing to flush and change the dressing on a client's central venous catheter. hemorrhage d. The nurse instructs the nursing assistant to apply the restraints. Sterile water C. Which of the following actions should the nurse take to provide the client with unbiased care? (Select all that apply. 3. It stimulates cell growth and growth of new blood vessels. Don sterile gloves The nurse is caring for a client who is to have a sterile dressing change to a wound. What is the nurse's first action? exerting equal, but not excessive, tension with each turn of the bandage wrapping distally to proximally elevating and Study with Quizlet and memorize flashcards containing terms like When changing a wet-to-dry dressing covering a surgical wound, what should the nurse do? A. Which of the following examples should the nurse use to show appropriate transcription of this dosage? The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Which of the following types of dressing should the nurse use? A. -Apply a skin protectant to the incision site. b. The initial postprocedure monitoring plan should include what? Select all that apply. Pack the wet dressing tightly into the wound. Peel across the abdomen from the right to the left. ebvsp quufou xlkp maret bpihi gnn ocloy soolv ceuf asymcf