The nurse is caring for a client with a deep wound that has tunneling. Following the dressing change, what factors are essential for the nurse to document? Select all that apply
1. Size and shape of the tunnel
2. Direction and number of tunnels
3. Type of drainage coming from the wound
4. Length of dressing needed to pack wound
5. Amount of irrigation poured into the tunnel
1. Size and shape of the tunnel
2. Direction and number of tunnels
3. Type of drainage coming from the wound
4. Length of dressing needed to pack wound
Rationale: Size and shape of the tunnel. The size and shape of the tunnel must be documented so the next person changing the dressing has that information as a guide. Direction and number of tunnels. The amount of tunnels and their direction must be documented so that the next person changing the dressing has that information as a guide. Type of drainage coming from the wound. It is essential to document the type of drainage in order to evaluate for the presence of infection. Length of dressing needed to pack wound. It is essential to document the length of dressing to provide information about the depth of the tunnel. Amount of irrigation poured into the tunnel. Irrigation is not indicated during the dressing change for tunneled wounds.
You might also like to view...
The nurse is preparing the care plan for a client who admitted to the unit after an abdominal hysterectomy to manage endometriosis. Which goal statements reflect the need for further development by the nurse?
Select all that apply. 1. The nurse will assess the vital signs every 2 hours. 2. The client will walk Q2h on the first postoperative day. 3. The client will report feeling better. 4. The client will begin a clear liquid diet on the first postoperative day. 5. The healthcare provider will prescribe oral analgesics on the first postoperative day.
A patient will be taking amiodarone [Cordarone]. Which baseline tests are necessary before this medication is started? (Select all that apply.)
a. Chest radiograph and pulmonary function tests b. Complete blood count with differential c. Ophthalmologic examination d. Renal function tests e. Thyroid function tests
The nurse is managing care for a patient with cirrhosis of the liver. The nurse teaches the patient about how to avoid injury that may result in bleeding. The patient asks the nurse why he is at risk to start bleeding
What is the best response by the nurse? 1. "Because your liver is injured and unable to manufacture platelets." 2. "Because your liver thickens your blood so it is less likely to clot." 3. "Because your liver is injured and cannot make clotting factors." 4. "Because your liver is breaking down your clotting factors too quickly."
For a pharmacy technician assigned to stock replenishment, which item would be considered a high-alert medication?
A. Potassium chloride injection 10 mEq/5 mL 30 mL B. Ipratropium bromide inhalation solution 0.02% 2.5 mL vials C. Epinephrine 0.1% syrings D. 5% dextrose and 0.45% sodium chloride injection USP 500 mL