A patient, with a non-healing abdominal wound, has obvious dead tissue throughout the wound bed. The nurse realizes that which of the following will need to be done to encourage this wound to heal?
1. debride devitalized tissue
2. keep the wound open to air
3. cover the wound with a sterile dry dressing
4. analyze the patient's diet to ensure adequate protein intake
1
Rationale: The patient has a compromised wound that contains devitalized tissue. Devitalized tissue is tissue that has been separated from the circulation and the body's antimicrobial defenses. Bacteria proliferate on wounds that contain dead tissue and debridement of these materials is essential to prevent an environment conducive to bacterial growth. The wound should not be kept open to air or covered with a sterile dry dressing. Analyzing the patient's diet to ensure adequate protein intake would be beneficial to support wound healing however the wound needs to be debrided.
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The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
a. Rapid measurement is useful for uncooperative younger children. b. Using the TMT is the most accurate method for measuring body temperature in newborn infants. c. Measuring temperature using the TMT is inexpensive. d. Studies strongly support the use of the TMT in children under the age 6 years.
The American Association of Critical-Care Nurses (AACN) sponsors certification in critical care nursing for several critical care subspecialties. What is the most important benefit of such certification for the profession of nursing?
A) Provides positive publicity for nursing B) Validates nurses' expert knowledge and practice C) Mandated by government regulations D) Demonstrates basic knowledge in the field
A preterm infant has been started on IV fluids. When assessing the patient, which findings would indicate to the nurse that goals for this therapy are being met? (Select all that apply.)
A. Intake greater than output by 24 hours B. Lack of tremors and irritability C. Respiratory rate of 35 breaths/minute D. Urine output of mL/kg/hour E. Urine specific gravity of < 1.012
A space of 12 feet or more allowing for formal communication between persons is termed:
a. intimate distance. b. personal distance. c. public distance. d. social distance.