What interventions will facilitate maintaining A.N.'s peripheral tissue perfusion?
What will be an ideal response?
• Elevate the burned extremity above the level of the heart to promote venous return and to prevent
excessive dependent edema formation.
• Perform active range-of-motion and stretching exercises every hour, assessing the level of pain
associated with efforts. Increasing pain with movement is a result of tissue ischemia. When pain
is not present, increased movement of the affected area will promote venous return and assist in
decreasing edema.
• Turn or reposition the patient at least every 2 hours.
• Evaluate appropriateness of using a circulating air bed. A circulating air bed disperses body
weight over a larger surface, which reduces pressure against the capillary beds, allowing for tissue
perfusion.
• Use a bed cradle or some other device to support the weight of the top covers to keep them off the
burned areas.
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When working with gay and lesbian families, which of the following must the community health nurse do first?
A) Determine if the union is legal or not. B) Confront personal biases about this type of family structure. C) Address the usual parental fears and concerns. D) Plan additional services to address children's delayed development.
As an LVN/LPN, the nurse's role in the nursing process is to gather information and work with the patient. In carrying out this role, which task can be delegated to the LPN/LVN nurse?
a. Interviewing the patient on admission b. Planning and evaluating the patient's care c. Checking vital signs and medication response d. Carrying out all steps of the nursing process
When examining a patient who has undergone a left simple mastectomy, the nurse should do which of the following?
a. examine the right breast first b. omit palpating the lymph nodes on the left side because they were removed c. turn her to her right side before palpation d. omit palpating the left nipple because it was removed
A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic oint-ment is to:
a. Destroy an infectious exudate caused by Staphylococcus that could make the in-fant blind. b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially ac-quired from the birth canal. c. Prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. Prevent the infant's eyelids from sticking together and help the infant see.