The home health nurse is going to visit a client w is being cared for by family members in the home that has a pressure ulcer. The nurse is going to change the dressing and observe the healing status
The wound is 6 × 7 cm and 2 cm deep and exposes muscle. What does the nurse document this wound as? A) Stage I
B) Stage II
C) Stage III
D) Stage IV
D
Feedback:
Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage II is the same as stage I but has a blister or shallow break in the skin. Stage III has superficial skin impairment that progress to a shallow crater that extends to the subcutaneous tissue.
You might also like to view...
A nurse is preparing to discharge a patient with an immunodeficiency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize?
A) Sterile technique for establishing a new IV site B) Signs and symptoms of adverse reactions C) Formulas for calculating daily doses D) Technique for adding medications to the IVIG
After delivery, a patient is diagnosed with placenta succenturiata. For what procedure should the nurse prepare this patient?
A) Lavage of the uterus B) Repair of an episiotomy C) Manual removal of accessory lobes D) Emergency resuscitation of the newborn
Care of the patient with glaucoma includes all of the following except
A. monitoring intake and output. B. avoiding tight and constrictive clothing. C. keeping the patient from stooping or lifting. D. keeping the patient in bed to avoid exertion.
The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?
a. firm fundus at the symphysis b. white, thick vaginal discharge c. striae that are silver in color d. soft breasts without milk