The nurse is caring for an 84-year-old client who was just admitted from a nursing home with a large sacral ulcer. When assessing the wound, the nurse notes small areas of both black and white tissue in the wound bed
The nurse understands that the best dressing protocol for this wound is: 1. Wet-to-dry with normal saline every 6 hours.
2. Petroleum-based antiseptic dressing once per day.
3. Dry dressing twice per day.
4. Wet-to-wet with Dankins solution once per day.
Wet-to-dry with normal saline every 6 hours.
Rationale: The black and white tissue needs to be debrided from the wound area before healing can occur. Wet-to-dry dressing provides a means of debridement. Petroleum-based products will not provide debridement. Dry dressing and wet-to-wet Dankins solution also will not provide the needed debridement.
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A 42-year-old African-American man with congestive heart failure has been prescribed hydralazine-isosorbide. The nurse will closely monitor for which of the following?
A) Hypertension B) Hypotension C) Decrease in body temperature D) Increased heart rate
Two nurses are talking about the number of patients that are admitted to the hospital each week due to falls in the home
They decide to partner up with the local senior center to design a community program aimed at reducing falls in the senior population. Which of the following interventions would likely be most effective? A. Create printed material that the seniors can take home and use to assess their home. B. Train volunteers to go into the homes of seniors at high risk for falls to assess their homes and help improve the home environment. C. Provide an exercise program in the community center to increase agility and balance. D. Pair up seniors at high risk with a volunteer caretaker who can help with chores and running errands.
A child is admitted to the emergency department with a head injury. The nurse makes an assessment and will record which of the following baseline data:
a. Pupil size b. Level of consciousness c. Vital signs d. All of the above
The nurse has provided education for a client prescribed zafirlukast (Accolate). Which statement made by the client indicates an understanding of the information?
A. "Zafirlukast will activate my fight-or-flight response." B. "I can use this prescription for acute asthma attacks." C. "This prescription will dilate my airways so I can breathe better." D. "This decreases the inflammation in my lungs."