The nurse is caring for a client who previously had a sacral pressure ulcer, which is now completely healed. In developing the risk profile for skin breakdown, the nurse recognizes that a prior pressure ulcer will:
1. Heal faster with reinjury.
2. Break down faster with reinjury.
3. Have no sensation in the injured area.
4. Be at risk for infection even with intact skin.
2. Break down faster with reinjury.
Rationale:
Scarred wounds never reach their prewound strength and, therefore, are more prone to reinjury than normal tissue. Sensation does return, and even though there is risk for breakdown, intact skin does not increase risk for infection.
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In an effort by the body to compensate for a low arterial pressure, the kidneys retain which electrolyte?
a. Sodium b. Glucose c. Potassium d. Chloride
The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. The best response by the nurse is:
1. "His head is molded from fitting through the birth canal. It will become more round." 2. "We refer to that as ‘cone head,' which is a temporary condition that goes away." 3. "It might mean that your baby sustained brain damage during birth, and could have delays." 4. "I think he looks just like you. Your head is much the same shape as your baby's."
The client gives correct information regarding ways to prevent a recurrence of her urinary tract infection when she states, "I should:
A. Wipe from back to front after urination." B. Urinate when I feel the urge." C. Try to restrict my intake of fruits." D. Use a diaphragm."
The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is dyspneic and has a bounding pulse
The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which of the following complications of blood transfusion therapy? 1. Bacteremia 2. Fluid overload 3. Hypervolemic shock 4. Allergic transfusion reaction