Which intervention for a small chronic ulcer should the nurse delegate to the nursing assistant?
1. Measure the wound for length, width, and depth.
2. Facilitate client hygiene after the dressing change.
3. Ask client to rate pain during the dressing change.
4. Examine wound bed for type and amount of tissue.
2
2. The nurse delegates client hygiene to the nursing assistant after the dressing change because the assistant is educated to perform this nursing task. The client has a better chance of increased comfort and refreshment when the nursing assistant provides client hygiene after the dressing change.
1, 3, and 4. The nurse assesses the wound for type and amount of tissue in the wound bed, measures the wound, and assesses client pain control to fulfill the duty the nurse owes to the client and because assessing is a nursing function and part of the nursing process.
You might also like to view...
A 25-year-old woman is in the clinic for her first prenatal visit. The nurse will prepare to obtain which laboratory screening test at this time?
a. Urine toxicology b. Complete blood cell count c. Alpha-fetoprotein d. Carrier screening for cystic fibrosis
Order: Dilantin Kapseals (phenytoin sodium, extended) 5 mg/kg PO, extended-release capsules divided in three equal doses. The label on the bottle reads, "30 mg/cap
" Calculate how many capsules you should administer for a child who weighs 40 pounds. 1. 1 capsule 2. 3 capsules 3. 2 2/3 capsules 4. 3 3/4 capsules
The parents of a patient with schizophrenia ask whether their child is likely to become violent. The best answer the nurse can give is that the vast majority of mentally ill individuals are:
a. somewhat more dangerous than ordinary people. b. definitely more violence-prone than others on the street. c. no more dangerous than other individuals in the population. d. considerably more dangerous than others in the population.
One of the most important things to check when preparing a room/bed area for a new individual is that: a. it has been cleaned from the last admission. b. the oxygen and suction are connected correctlyand working
c. the equipment in the room (such as call button)is functioning. d. all of the above.