The nurse is preparing to apply dressings to a patient's partial-thickness burn wounds. What should the nurse keep in mind when applying these dressings? (Select all that apply.)
a. Wrap digits as one dressing.
b. Elevate affected extremities.
c. Limit the amount of dressing bulk.
d. Wrap extremities from distal to proximal.
e. Double the estimated size of dressing material.
ANS: B, C, D
General principles for dressings include elevating the affected extremities, limiting the bulk of the dressing to facilitate range of motion, and wrapping extremities from distal to proximal to promote venous return. A. Never wrap skin-to-skin surfaces. E. The size of the dressings should be based on the size of the wounds, absorption, protection, and type of debridement.
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A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
a. Collect history information first, then perform the physical examination and institute life-saving measures. b. Simultaneously ask history questions while performing the examination and initiating life-saving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.
A patient has these nursing diagnoses. Prioritize them, beginning with the highest priority
A. Social isolation B. Spiritual distress C. Self-care deficit syndrome
An older adult has been diagnosed with a sinus infection. To minimize the risk for a fall-related injury, the nurse teaches the patient
a. that there is a possibility of prodromal falls. b. to take her antibiotic medication with food. c. to recognize symptoms of fluid buildup in the middle ear. d. about the increased risks of falls related to normal aging.
The nurse also assesses Mr. Morrow's limb measurements. Where should the nurse measure arm length?
A) From the humerus to the tip of the middle finger B) From the humerus to the wrist C) From the acromion process to the tip of the middle finger D) From the acromion process to the wrist