An older patient has a nonhealing stage III pressure ulcer. Which treatment would be indicated for this patient's wound?
1. Cadexomer
2. Silver sulfadiazine
3. Nanocrystalline silver
4. Topical antibiotic cream
2
Rationale: Cadexomer iodine dressings provide a slow-release form of iodine. These dressings have effective antibacterial action and do not harm granulation tissue. The patient's wound is not healing and would not have granulation tissue.
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A client scheduled for a repair of an abdominal aortic aneurysm reports increased abdominal pain accompanied by new onset of intense back and flank pain. The priority action by the nurse would be to
a. administer a prescribed analgesic. b. notify the physician immediately. c. reassess the client in another 5 minutes. d. take another set of vital signs.
Which statement, if made by a new circulating nurse, is appropriate?
a. "I will assist in preparing the operating room for the patient." b. "I will remain gloved while performing activities in the sterile field." c. "I will assist with suturing of incisions and maintaining hemostasis as needed." d. "I must don full surgical attire and sterile gloves while obtaining items from the unsterile field."
A suspicious client has been placed in a room with a roommate. The night nurse reports that this client has been awake for the past three nights. The likely explanation for his wakefulness is which of the following?
A) He is fearful of what his roommate might do to him while he sleeps. B) He is a light sleeper and unaccustomed to a roommate. C) He is watching for an opportunity to escape. D) He is worrying about his family problems.
A pt in the hospital being treated for a PE is receiving a continuous infusion of heparin. When the nurse comes to take vs, the pt has blood on the front of his chest and nose and is holding a tissue saturated with blood to his nose. What is the first priority action the nurse must take?
a. have the pt sit up and lean forward, pinching the nostrils b. have a pt care technician set up oral suctioning to suction excess blood from pts mouth c. stop the heparin IV infusion d. obtain lab results for prothrombin time and CBC