Skin integrity HESI

In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform?

Apply light pressure to the area with the fingertips.

Measure the diameter of the redness.

The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document?

Reactive hyperemia.

Which areas are most important for the nurse to observe for additional pressure ulcers?

Heels and ankles.

What action should the nurse implement?

Identify these areas as sites where pressure damage has occurred.

Which etiology identified by the nurse is accurate?

Impaired physical mobility.

Which goal will the nurse include in Alexander's plan of care?

Client's skin will remain intact.

To provide pressure relief at night, the nurse teaches Alexander to sleep in which position?

Thirty-degree lateral inclined position.

Upon learning that Alexander has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take?

Encourage him to continue to use this device in his wheelchair at all times.

The nurse teaches Alexander to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 pressure ulcer?

Transparent film dressing.

Which documentation best describes the drainage from Alexander's wound?

Purulent

Which intervention is important to reduce the effect of the diarrhea on Alexander's skin?

Apply a moisture-repellent ointment to intact skin areas.

What action should the nurse take?

Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights.

After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client?

Contact precautions.

Which equipment will the nurse use to assess the length of the tract?

Sterile cotton-tipped applicator.

Which irrigation technique is best?

Apply steady pressure using a 35 mL syringe and 19 gauge needle.

What is the purpose of this type of dressing?

Mechanically debride the tissue.

How many mL of medication will the nurse administer? (Enter numerical value only. If rounding is necessary, round to the whole number.)

20

Fill in the blank

What is the total daily dosage (in mg) that Alexander will be receiving? (Enter numerical value only. If rounding is necessary, round to the whole number.)

800

Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy?

Pharmacist

Which technique should the nurse use to mix the linezolid?

Turn the bottle upside down 3 to 5 times.

The nurse correctly uses which technique when pouring the suspension?

Place the medication cup on a flat surface at eye level.

What should the nurse assess Alexander for during the course of antibiotic therapy?

Visual changes.

Which laboratory values should be monitored during the course of antibiotic treatment with linezolid?

CBC

Which side effects should the nurse include when teaching Alexander about linezolid therapy?

Visual changes.

Diarrhea.

Abdominal cramping.

Itching.

The nurse explains to Alexander that this precaution reduces the risk for what potential problem?

Anaphylactic reaction.

Which class of medication should the nurse expect to administer?

An antihistamine, such as diphenhydramine.

Which diagnostic test should the nurse request a prescription for to determine if Alexander is developing drug toxicity?

Peak and trough.

What initial action should the nurse take?

Offer Alexander the opportunity to discuss his feelings of anger and hopelessness.

How should the respond respond to Alexander's statement?

"You are trying to cope with a lot of concerns right now."

Considering Alexander's developmental stage at the age of 20, the nurse's plan of care emphasizes interaction with which group?

Alexander's girlfriend and his two best male friends from the college.

It is most important to include this group in which aspect of Alexander's overall care?

Reviewing class notes and studying for exams.

The nurse encourages him to select which breakfast items to provide a good source of protein?

Eggs and orange juice.

What teaching should the nurse provide?

Hydrocolloid dressings should be continued over the ulcer.