The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?
a. visible subcutaneous
... [Show More] fat
b. exposed bone with eschar
c. nonblanchable redness
d. a shallow open injury correct answers c
After Impaired Skin Integrity, which of the following NANDA-I nursing diagnoses would be a priority for a patient who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?
a. Anxiety
b. Ineffective Coping
c. Risk for Infection
d. Risk for Situational Low Self-Esteem correct answers c
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?
a. improving the client's hydration
b. lubricating the area with skin oil
c. pulling the client up from under the arms
d. preventing the client from sliding in bed correct answers d
The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?
a. Measure length, width, and depth of the wound.
b. Massage the healthy tissue surrounding the wound.
c. Document the color, odor, amount, and type of wound drainage.
d. Determine the extent of wound undermining. correct answers c
A nurse is collaborating with the interdisciplinary team to develop a nutritional plan for a patient with a nonfunctional GI tract due to a massive small bowel resection. Which of the following nutrition interventions would be most appropriate?
a. Parenteral nutrition
b. Enteral nutrition
c. High fiber diet
d. Regular diet correct answers a
A nurse is feeding a patient. Which statement would help a person maintain dignity while being fed?
a. 'I wish I had more time so I could feed you all of your meal.'
b. 'I am going to feed you your cereal first and then your eggs.'
c. What part of your dinner would you like to eat first?'
d. 'I know you don't like me to feed you, but you need to eat.' correct answers c [Show Less]