The nurse systematically assesses the ulcer and confirms the presence of a stage III wound with moderate drainage. There is no tissue necrosis or debris. What does it mean to "stage a pressure ulcer"?
What will be an ideal response?
Answer: Staging an ulcer involves noting the different tissue layers involved in the insult.
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A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min
The patient shouts, "Bugs are crawling on my bed. I've got to get out of here.". Select the most accurate assessment of this situation. The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol-withdrawal delirium. d. is having an acute psychosis.
A client has been prescribed benzphetamine. Which intervention would be most appropriate for the nurse to implement while administering the drug?
A) Provide tea, coffee, and other stimulants. B) Administer the drug around dinner time. C) Avoid administering antidepressants. D) Encourage the intake of carbonated caffeine beverages.
Which of the following medications possesses positive inotropic effects, allows the cellular uptake of glucose, and is used in the treatment of hyperkalemia?
A) Insulin B) Osmitrol C) Glucophage D) Clopidogrel
The nurse is reviewing the exchange of gases in the blood stream with a patient prescribed oxygen therapy. How should the nurse explain the transport of carbon dioxide in the blood?
a. As CO2 in plasma b. As bicarbonate ions in plasma c. As hydrogen ions in red blood cells d. As part of hemoglobin in red blood cells