The nurse is assessing a periwound area on a client with a large abdominal wound, and the area appears macerated. What change in nursing management is required due to the maceration?
1. Keep the moist dressing off the periwound area.
2. No new measures are necessary, as this is a normal finding.
3. Apply a moist dressing to the periwound area.
4. Apply a petroleum-based product to the periwound area.
Keep the moist dressing off the periwound area.
Rationale: Maceration occurs when excessive moisture destroys the skin's integrity. Periwound skin becomes macerated when the wet dressing from the wound extends to the skin around the wound. The most appropriate nursing measure is to not have any wet dressing touching the skin around the wound. Maceration is not a normal finding and requires nursing intervention. Applying moist dressings to the periwound area would worsen the maceration. Applying a petroleum dressing to the periwound is not necessary. All that is necessary is to keep the area dry and let the skin heal.
You might also like to view...
Immediately after a client dies, who is the nurse responsible for notifying?
1. Family 2. Primary care provider 3. Funeral home 4. Coroner, if indicated
The nurse has completed discharge teaching with a patient who had a mechanical valve replacement. Which patient behavior would the nurse evaluate as indicating additional teaching is necessary?
1. The patient asks his wife to purchase a blood pressure monitor from their pharmacy. 2. The patient tells the nurse of his plans to visit Rome next year. 3. The patient orders a pasta salad with broiled salmon for lunch. 4. The patient makes plans to stay with his daughter in her three-story condominium for a few weeks after discharge.
The nurse is reviewing the drugs ordered for a patient. A drug interaction occurs between penicillins and which drugs. (select all that apply)
A. Alcohol B. Oral Contraceptives C. Digoxin D. Nonsteroidal antiinflammatory drugs E. Warfarin F. Anticonvulsants
A 65-year-old man is diagnosed with type 2 diabetes mellitus. Which patient symptom(s) would indicate type 1 diabetes mellitus and not type 2? (Select all that apply.)
a. Impotence b. Increased thirst over the past week c. A 10-pound weight loss within the past month d. Polyphagia e. Ketoacidosis