The nurse is caring for a frail, elderly patient who has a chronic pressure ulcer on the ankle
The nurse plans care to reverse which factors that impair healing in the wound? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Repeated prolonged insults to the tissue
2. Patient's lack of concern about the wound
3. An inadequate blood supply in the tissue
4. Newly diagnosed urinary tract infection that may have been present for some time
5. Recent laceration on the other leg
1,3,4
Rationale 1: Wounds generally become chronic because of repeated prolonged insults to the tissue.
Rationale 2: The patient's lack of concern about the wound is not directly related to healing.
Rationale 3: Wounds generally become chronic because of inadequate blood supply in the tissue.
Rationale 4: Chronic infection may affect the ability to heal from chronic wounds and represents a disruptive underlying pathologic process.
Rationale 5: Recent trauma is associated with acute traumatic wounds and would not affect the status of the chronic wound.
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a. Assess the fetal heart rate pattern over the next 30 minutes. b. Take the patient's blood pressure every 5 minutes for 15 minutes. c. Determine the patient's contraction pattern for the next 30 minutes. d. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hr over 30 minutes.
An APHN is working as an administrator. Which of the following would the nurse most likely be doing?
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The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions first?
1. Ensure that the client has voided. 2. Administer all the daily medications. 3. Practice postoperative breathing exercises. 4. Verify that the client has not eaten for the last 24 hours.
One minute after delivery the following is assessed in a neonate: heart rate 120 beats per minute, vigorous cry, actively moving, resists attempts to straighten an arm, facial grimace with sole flicking, body pink, extremities blue
What Apgar score should the nurse assign to this infant? 1. 6 2. 7 3. 8 4. 9