A pre-teen quadriplegic patient was admitted with pressure ulcers to both ankles. The nurse should assess which parameters for a wound assessment? (Select all that apply.)
a. Size
b. Viable versus nonviable tissue
c. Tissue type involvement
d. Preventive measures
e. Anatomical location
A, B, C, E
Wound assessment (regardless of cause) includes the following parameters: anatomical location, extent of tissue involvement (full or partial thickness loss), size (dimensions and depth of wound), tissue type (viable or nonviable) and percentage of wound tissue (e.g., viable vs. nonviable), volume and color of wound exudate, and condition of surrounding skin.
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A patient diagnosed with bursitis asks the nurse, "Why do you keep asking what my pain level is? Don't you believe me?" How should the nurse respond?
1. "It is important to know your pain level so that we can provide you with the best medication." 2. "If you don't want the medication, you don't have to take it." 3. "I can't give you the medication unless I know what your pain level is." 4. "I don't understand why you are concerned about my questions. Would you clarify?"
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation
How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
Jeffrey has atopic dermatitis. You are prescribing a low-dose topical corticosteroid for him. Which would be a good choice?
a. Betamethasone dipropionate 0.05% c. Halcinonide 0.1% b. Hydrocortisone base 2.5% d. Desonide 0.05%
A nurse collects objective data on a client during a health assessment that includes the client's:
A) blood pressure. B) fatigue level. C) presence of pain. D) symptoms of nausea.