The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is t
“Use lots of moisturizer several times a day to minimize dryness.”
“After you bathe, put lotion on before your skin is totally dry.”
“Use antimicrobial soap to avoid infection of cracked skin.”
“Take a cold shower instead of soaking in the bathtub.”
Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with
A 78-year-old requiring assistance to ambulate with a walker
A 44-year-old prescribed IV antibiotics for pneumonia
A 65-year-old with hemi-paralysis and incontinence
A 26-year-old who is bedridden with a fractured leg
“Bottoming out,” as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.
Do nothing because this is an expected occurrence.
Turn the mattress overlay to the opposite side
Apply a different pressure-relieving device.
Apply a different pressure-relieving device.
Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be l
Assess the wound bed once a day.
Change the dressing when it is saturated.
Contact the provider when the dressing leaks.
Change the dressing every 6 hours.
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmet
Assess the right leg for pulses, skin color, and temperature.
Place the client in bed and instruct the client to elevate the foot.
Draw blood for albumin, prealbumin, and total protein.
Prepare for and assist with obtaining a wound culture.
Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a cli
“I can help him shift his position every hour when he sits in the chair.”
“Drinking a nutritional supplement between meals will help maintain his weight.”
“If his tailbone is red and tender in the morning, I will massage it with baby oil.”
“Applying lotion to his arms and legs every evening will decrease dryness.”
The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat
High-protein diet with vitamins and mineral supplements
Low-fat diet with whole grains and cereals and vitamin supplements
Vegetarian diet with nutritional supplements and fish oil capsules
Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet
A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.
Client whose wound has decreased in size
Client with a white blood cell count of 23,000/mm3
Client who has thin, serous wound drainage
Client with blood cultures pending
The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential
Client admitted from a nursing home with furuncles and folliculitis
Client transferred from intensive care with an elevated white blood cell count
Client with a leg cut and other trauma from a motorcycle crash
Client with a rash noticed after participating in sporting events
Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious proce
“I’ll apply cortisone cream to reduce the inflammation.”
“I’ll cleanse the area prior to applying antibiotic cream.”
“I’ll keep my arm down at my side to prevent spread.”
“I’ll apply a clean dressing after squeezing out the pus.”
The client’s presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an
Place the client in a single room.
Apply gloves to minimize friction.
Administer an antihistamine.
Assess the client’s airway.
For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does n
“Good hand hygiene is the only thing that really matters with wound care.”
“You can use tap water instead of sterile saline to clean your wound.”
“If you don’t clean the wound properly, you could end up in the hospital.”
“Sterile procedure is necessary to keep this wound from getting infected.”
Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment shoul
“I have to make sure I keep my lesions covered, so I do not spread this to others.”
“I expect that these patches will get smaller when I lie out in the sun.”
“At the next family reunion, I’m going to ask my relatives if they have psoriasis.”
“I should continue to use the cortisone ointment as the patches shrink and dry out.”
This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign co
Irregular blue mole with white specks on the lower leg
Large cluster of pustules in the right axilla
Beige freckles on the backs of both hands
Thick, reddened papules covered by white scales
Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to “red man syndrome”), it is not customary to administer diphenhydramine befor
Give the client diphenhydramine (Benadryl) before the drug.
Administer it over 30 minutes using an IV pump.
Ensure that the client has increased oral intake during therapy.
Assess the IV site at least every 2 hours for thrombophlebitis.
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