The nurse is demonstrating a dressing change to a nursing student. What key safety features should she emphasize during the process? (Select all that apply.)
a. Knowing the type of wound
b. Knowing the expected amount of drainage
c. Knowing the patient's blood type
d. Knowing whether drainage tubes are present
A, B, D
It is important to:
1 . Know the cause or type of wound. Wounds caused by vascular insufficiency, diabetes mellitus, pressure, trauma, and surgery are all very different and must have an individualized treatment plan. Not knowing the cause of a wound can have serious negative effects if treatments that are contraindicated for certain types of wounds are used.
2 . Know the expected amount and type of wound exudate or drainage. Wounds with large amounts of drainage require more frequent dressing changes or need an absorptive dressing.
3 . Determine whether wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing.
Knowing the patient's blood type is not necessary for the purposes of changing the dressing unless you are expecting a bleeding complication, and then it would be important for the patient to have a blood type and screen done.
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The nurse is instructing a client recovering from arterial aneurysm repair. Which of the following should be included in these instructions? (Select all that apply.)
1. Do not lift anything heavier than 15 to 20 lbs. 2. Limit activity for up to 8 weeks after the surgery. 3. Use a pillow to splint when coughing. 4. Driving is permitted 1 week after surgery. 5. Notify the physician for pain, redness, or swelling around the incision. 6. Avoid pain medication.
The nurse is performing a focused bowel assessment on an older adult. Which of the following physiological changes of aging should alert the nurse to an increased risk for problems associated with bowel elimination? Select all that apply
a. Decreased sphincter control b. Decreased peristalsis c. Increased intestinal muscle tone d. Decreased physical activity
The nurse is preparing to examine several clients in the clinic setting. Which of the following clients would need the greatest degree of special consideration during a physical examination?
1. 59-year old with flu symptoms 2. 3-year-old child in for a well check-up 3. 17-year old who complains of fatigue 4. 68-year old with chronic lung disease
The nurse is thoroughly assessing the client for any peripheral vascular problems. The client requested the nurse to state exactly what the nurse was looking for during the assessment
Which of the following statements by the nurse are unexpected? Standard Text: Select all that apply. 1. "I am feeling your feet to see how warm they are.". 2. I am looking for hair on your toes.". 3. I am going to perform the Trendelenburg's test to see how well the radial and ulnar arteries are supplying blood to your hand.". 4. I am going to test your ability to feel sensations by giving you an injection.". 5. "I am going to perform the Allen's test to see if you have any varicose veins.".