A client has a large, sacral pressure ulcer with a red wound base and no drainage. Which solution would the nurse select as the most appropriate solution for cleansing this wound?
a. A weak iodine solution
b. Dakin's solution
c. Half-strength hydrogen peroxide
d. Normal saline
D
Normal saline (NS) is the only solution recommended by the American Healthcare Policy and Research (AHCPR) group for wound care, such as in packing and cleaning. NS is physiologic, will not harm tissues, and adequately cleans most wounds. Iodine solutions, half-strength perox-ide, and Dakin's solutions can be used for the short-term management of infected wounds.
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A patient has lost his home and family as a result of an addiction to alcohol. What does the nurse understand about the patient's condition?
1. Addictive behavior involves the limbic system. 2. Addictive behavior is indicative of character flaws. 3. Addictive behavior has a variety of neurological patterns. 4. Addictive behavior is related to dysfunctional parent-child relationships.
A patient received a right hip prosthesis after a fall. In the immediate postoperative period, the nurse should maintain the leg:
A) In an abducted position. B) In an adducted position. C) In a neutral position. D) With the hip flexed greater than 90 degrees.
The obese postsurgical patient complains of sudden discomfort in her leg. The nurse assesses the leg and finds it cold and pale, with no pedal or popliteal pulse. These are signs of:
1. venous thrombosis. 2. arterial occlusion. 3. vascular spasm. 4. paresthesia.
The nurse is preparing to administer a drug and learns that it binds to protein at a rate of 90%. The patient's serum albumin level is low. The nurse will observe the patient for
a. decreased drug absorption. b. decreased drug interactions. c. decreased drug toxicity. d. increased drug effects.