A client's burn wound is being treated with enzymatic debridement. At this time the nurse would assess the client for
a. allergic reactions.
b. bleeding from the burn wound.
c. increased fluid loss.
d. serum electrolyte imbalances.
B
Enzymatic debridement involves the application of commercially prepared proteolytic and fibrinolytic topical enzymes to the burn wound, which facilitates eschar removal. As the enzyme digests necrotic tissue, it also opens up thrombosed blood vessels. This results in some oozing of blood from the vessels, as well as a site for bacteria to enter the bloodstream.
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The nurse explains to the client that several causes of incontinence are reversible. Which of the following should be included? (Select all that apply.)
a. restricted mobility d. delirium b. polyuria e. nocturia c. infections f. increased calcium intake
Mrs. Mayes is a 73-year-old woman who has a diabetic foot ulcer that has been extremely slow to heal and which now poses a threat of osteomyelitis
The wound care nurse who has been working with Mrs. Mayes applies evidence-based practice (EBP) whenever possible and has proposed the use of maggot therapy to debride necrotic tissue. Mrs. Mayes, however, finds the suggestion repugnant and adamantly opposes this treatment despite the sizable body of evidence supporting it. How should the nurse reconcile Mrs. Mayes' views with the principles of EBP? A) The nurse should explain that reliable and valid research evidence overrides the patient's opinion. B) The nurse should explain the evidence to the patient in greater detail. C) The nurse should integrate the patient's preferences into the plan of care. D) The nurse should involve the patient's family members in the decision-making process.
Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration?
a. Clear liquids b. Adsorbents, such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric
A healthcare professional cares for older adults in a skilled nursing facility. What should the professional assess for in these individuals related to cardiovascular functioning?
a. Increased rate of falling and dizzy spells b. Improved exercise tolerance c. A gradual slowing of the heart rate d. Progressive ECG changes