The wound nurse needs to evaluate the preexisting pressure ulcer. She gently removes the old dressing,
using the push-pull method and adhesive remover wipes.
After taking off the outside dressing, often
called a secondary dressing, she pulls out the primary dressing and states that R.L. has a tunneled wound
that was "packed too hard."
What problems can be created by packing a wound too full?
As wounds heal, they contract. If a wound is packed too tightly, it creates a pressure insult to the
wound bed and causes a secondary pressure ulcer or further tunneling.
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At mealtime, the older adult seems to be eating less food than would be adequate. Compared to the younger adult, what is a requirement for the older adult?
a. More fluids b. Less calcium c. Fewer calories d. More vitamins
The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
A) The client has cerebral spinal fluid (CSF) leaking from the ear. B) The client has ecchymosis in the periorbital region. C) The client has an elevated temperature. D) The client has serous drainage from the nose.
The client has been started on Detrol LA and tells the nurse that he is experiencing constipation. What is the highest priority action on the part of the nurse?
a. Hold the next dose of the medication; this is an adverse reaction. b. Administer the drug: this is an expected response to the drug. c. Notify the physician; this is a side effect of the medication. d. Call the pharmacist; this is evidence of toxicity of the drug.
Which statement about the pain of myocardial infarction is correct?
a. It is usually gradual onset with mild pain, felt on the left side. b. It is often described as crushing, stabbing, or squeezing. c. It may radiate to both knees, feet, and toes. d. It is relieved by rest and nitroglycerin.