A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?
a. A patient with a clean Stage I
b. A patient with a clean Stage II
c. A patient with a clean Stage III
d. A patient with a clean Stage IV
ANS: A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. A composite film, hydrocolloid, or hydrogel can be utilized on a clean Stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage III. Hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage IV. An unstageable wound covered with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes.
You might also like to view...
A client who grew up with alcoholic parents is reluctant to discuss thoughts, feelings, and self-defeating behaviors with the nurse. Which of the following responses by the nurse would be most helpful?
1. "We don't have to talk about your feelings if you don't want to. Let's discuss the behaviors you would like to change." 2. "Some clients who were raised in alcoholic families are reluctant to discuss their feelings. How has this impacted you?" 3. "I understand that you are not used to discussing your feelings; however, we can't continue unless you open up to me." 4. "I understand that opening up to others is difficult for you, but you need to change your view about discussing family issues with me."
Certain individuals are born with the skills for management and these skills cannot normally be learned
Indicate whether the statement is true or false
The nurse is assessing a young toddler-age patient. Which assessment finding may contribute to dental caries
1) Bottle of milk before bed 2) Bottle of juice before bed 3) Pacifier dipped in honey 4) All of the above
MC The nurse is aware that many members of the community, though they are employed, need to obtain additional foodstuffs every month from the local community food bank. The nurse knows that this indicates that
A. There are insufficient employment opportunities in the community. B. Poverty is increasing in the community. C. Better information about food economy should be disseminated in the community. D. The local grocery stores do not carry sufficient supplies.