Author Question: A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer ... (Read 123 times)

arivle123

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A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?
 
  a. A patient with a clean Stage I
  b. A patient with a clean Stage II
  c. A patient with a clean Stage III
  d. A patient with a clean Stage IV

Question 2

The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?
 
  a. Monitor vital signs every 15 minutes.
  b. Check pulses in the right foot.
  c. Keep the leg dependent.
  d. Apply ice.



CAPTAINAMERICA

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Answer to Question 1

ANS: A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. A composite film, hydrocolloid, or hydrogel can be utilized on a clean Stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage III. Hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage IV. An unstageable wound covered with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes.

Answer to Question 2

ANS: D
Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation (not dependent) assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.



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