The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by doing which one of the following?
a. Filling two-thirds of the wound cavity
b. Leaving saline-soaked folded gauze squares in place
c. Putting the dressing in very tightly
d. Extending only to the surface of the wound
D
The wound should be packed only until the packing material reaches the surface of the wound. Wound packing that overlaps onto the wound edges may cause maceration of the tissue sur-rounding the wound.
The wound should be packed to the upper edge of the wound to prevent dead space and the formation of abscesses.
The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound.
The wound should not be packed too tightly. Over-packing the wound may cause pressure on the tissue in the wound bed.
You might also like to view...
The nurse teaches a client about lifestyle modifications to help manage hypertension. Which client statement indicates teaching has been effective?
A) "I won't be able to run in marathons anymore." B) "I know I need to give up my cigarettes and alcohol." C) "I need to get started on my medications right away." D) "My father had hypertension, did nothing, and lived to be 90 years old."
An 80-year old-woman who lives alone has begun calling friends and complaining in an exaggerated
fashion about minor aches and pains. Her physician found no significant medical problems. Over the course of a month, she obtained a number of prescriptions for pain medication, none of which seemed to be effective. Friends counseled her that aches are a normal part of life for the elderly and tried unsuccessfully to involve her in activities. She often suggested that she would be better off dead, to which one friend responded "Well, perhaps. It would get you out of your misery.". As she became increasingly "needy" and demanding of attention, friends agreed that her behavior made them uncomfortable and began to call and visit less. The woman took four pain pills and called a neighbor, saying she had overdosed. After medical clearance, the client will be monitored at the mental health clinic. Principles of paramount importance to care planning in this instance include (more than one answer may be correct): A. Parasuicide with lethal intent requires emergency hospitalization. B. The client should be treated for underlying psychiatric disorder if one exists. C. Client perception of isolation is a significant cause for hopelessness. D. A nonlethal suicide attempt must be viewed as communication of the client's desperate state of mind.
Round face, preauricular fat, hyperpigmentation, and "buffalo hump" in the posterior cervical area are associated with:
a. infantile hydrocephalus. b. acromegaly. c. Cushing syndrome. d. achondroplasia.
The operating room holding area is calling for the nurse in ambulatory surgery to bring the client to the holding area now. The nurse reviews the chart and discovers that the surgical consent form has not been signed. What is the nurse’s best action?