This topic contains a solution. Click here to go to the answer

Author Question: The UAP reports a small skin tear on the client's forearm that occurred during a routine turn. After ... (Read 51 times)

jjjetplane

  • Hero Member
  • *****
  • Posts: 556
The UAP reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound the nurse should:
 
  1. Obtain a transparent dressing for the UAP to place on the wound.
  2. Request a consult with the wound care nurse.
  3. Cleanse the wound and apply a dressing.
  4. Tell the UAP to reevaluate the wound in 20 minutes.

Question 2

The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center.
 
  Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?
  1. There is undermining of adjacent tissues.
  2. The crater extends into the subcutaneous tissue.
  3. The joint capsule of the hip is visible.
  4. The ulcer has thick dark eschar over the top.

Question 3

After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure.
 
  One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?
  1. Reactive hyperemia
  2. Stage I pressure ulcer
  3. Stage II pressure ulcer
  4. Stage III pressure ulcer



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

sylvia

  • Sr. Member
  • ****
  • Posts: 331
Answer to Question 1

Correct Answer: 3
Rationale 1: The UAP is not educationally prepared to dress the wound.
Rationale 2: At this point a consult with the wound care nurse is not required.
Rationale 3: The nurse should go to the room, assess the wound, cleanse the wound, and apply a dressing.
Rationale 4: The UAP is not educationally prepared to evaluate the wound.

Answer to Question 2

Sent you a message please check your forum inbox. Thank you

Answer to Question 3

Correct Answer: 1
Rationale: If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred. Stage I pressure ulcers are reddened areas that do not blanch with thumb pressure and that do not clear in the allotted amount of time. Stage II pressure ulcers show partial-thickness skin loss and have the appearance of abrasions, blisters, or shallow craters. Stage III pressure ulcers demonstrate full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.




jjjetplane

  • Member
  • Posts: 556
Reply 2 on: Jul 23, 2018
YES! Correct, THANKS for helping me on my review


kthug

  • Member
  • Posts: 332
Reply 3 on: Yesterday
:D TYSM

 

Did you know?

The U.S. Pharmacopeia Medication Errors Reporting Program states that approximately 50% of all medication errors involve insulin.

Did you know?

Adolescents often feel clumsy during puberty because during this time of development, their hands and feet grow faster than their arms and legs do. The body is therefore out of proportion. One out of five adolescents actually experiences growing pains during this period.

Did you know?

Illicit drug use costs the United States approximately $181 billion every year.

Did you know?

Giardia is one of the most common intestinal parasites worldwide, and infects up to 20% of the world population, mostly in poorer countries with inadequate sanitation. Infections are most common in children, though chronic Giardia is more common in adults.

Did you know?

Over time, chronic hepatitis B virus and hepatitis C virus infections can progress to advanced liver disease, liver failure, and hepatocellular carcinoma. Unlike other forms, more than 80% of hepatitis C infections become chronic and lead to liver disease. When combined with hepatitis B, hepatitis C now accounts for 75% percent of all cases of liver disease around the world. Liver failure caused by hepatitis C is now leading cause of liver transplants in the United States.

For a complete list of videos, visit our video library