The nurse documents the first sign of a pressure ulcer that has not yet progressed to stage 1 when noting which of the following?
1. Nonblanchable reddened area on the coccyx
2. Mushy area on the buttocks that is cool to the touch
3. Wound covered with eschar
4. A blister on the buttocks
2
Rationale: Before nonblanchable erythema appears, many clients develop an area that suggests deep tissue injury evidenced by pain, a mushy or boggy area that can be cool or warm to the touch. Nonblanchable erythema is a stage 1 pressure ulcer. A wound covered with eschar is a stage 4 or unstageable tissue injury. A blister is a stage 2 pressure ulcer.
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During peritoneal dialysis
A) the dialysate is pumped into the peritoneal cavity. B) fluid is drained out by gravity. C) the effluent is a sterile fluid. D) the procedure is repeated continuously for about three to four hours.
The client is receiving 150 mL of 5.0% saline intravenously in the next 2 hours. What response should the nurse expect as a result of this therapy?
A. Increased blood pressure B. Increased dependent edema C. Increased urine concentration of potassium D. Increased hematocrit and hemoglobin levels
To what do you attribute these changes?
Jenny is one of your favorite patients who usually shares a joke with you and is nattily dressed. Today she is dressed in old jeans, lacks makeup, and avoids eye contact. A) She is lacking sleep. B) She is fatigued from work. C) She is running into financial difficulty. D) She is depressed.
A/an exacerbation is the improvement worsening of a chronic medical condition
Indicate whether the statement is true or false