Random/Wounds
Rate the Braden scale
!)Sensory perception
2)Moisture
3)Activity
4)Mobility
5)Nutrition
6)Friction and shear
What is the most important assessment before giving digoxin?
Apical pulse for 1 full minute (hold if <60 bpm in adults)
A provider orders 0.5 g of metformin PO. The supply is 250 mg tablets. How many tablets will the nurse give?
0.5 g = 500 mg
500 mg ÷ 250 mg = 2 tablets
What is the best position for a patient with a dehisced abdominal wound?
Low Fowler’s with knees flexed.
An older adult client has a healing surgical wound and a low Braden Scale score. The nurse reviews the client’s dietary intake. Which nutritional component should the nurse prioritize to promote optimal tissue repair and skin integrity?
High-quality protein
What stage pressure injury affects the topmost layer of the skin (epidermis)?
Stage 1 pressure injury
What is the primary therapeutic effect of hydrochlorothiazide (HCTZ)?
Decreases blood pressure by promoting sodium and water excretion (diuresis)
A patient is ordered 1,000 mcg of digoxin PO. Available is 0.25 mg tablets. How many tablets?
0.25 mg = 250 mcg
1,000 mcg ÷ 250 mcg = 4 tablets
What does necrotic tissue look like in a wound?
Black, dry, leathery (eschar).
A client with limited mobility is sitting in a bedside chair. To minimize the risk of shear and localized pressure development over the ischial tuberosities, the nurse should instruct the client or assist them to shift their weight at least every:
15 to 30 minutes
What phase of wound healing has granulation tissue?
Proliferation phase
What is the key teaching for a patient taking metformin regarding a serious risk?
Report signs of lactic acidosis (muscle pain, fatigue, rapid breathing)
A nurse must give 1.5 g of HCTZ PO. The tablets are 500 mg each. How many tablets?
1.5 g = 1500 mg
1500 ÷ 500 = 3 tablets
Atenolol belongs to which class?
Beta-blocker
Adequate fluid intake prevents systemic dehydration, preserves cellular fluid volumes, improves skin turgor, and makes the skin more resilient against external pressure forces.
Encouraging adequate oral fluid intake to maintain hydration and skin turgor (unless contraindicated).
What is used to reverse opioid overdose?
Naloxone (Narcan)
What is the main teaching for a patient taking glipizide?
Eat regular meals to prevent hypoglycemia
A nurse administers 2.5 g of furosemide IV. Available is 500 mg/10 mL. How many mL?
2.5 g = 2500 mg
2500 ÷ 500 = 5
5 × 10 mL = 50 mL
What is the class for glipizde?
Sulfonylurea-oral antidiabetic
A nurse has finished providing care to a client assigned to contact and droplet precautions for an undiagnosed respiratory wound infection. According to standard CDC guidelines, what is the correct sequence for removing personal protective equipment (PPE)?
Gloves, Goggles, Gown, Mask
What does slough tissue look like in a wound bed?
Yellow or white, soft, stringy, necrotic tissue.
. What is the most important teaching for alprazolam (benzodiazepine)?
Avoid alcohol and CNS depressants due to risk of severe respiratory depression
A provider orders 1 tbsp of liquid medication equivalent to 15 mL. The medication available is labeled 30 mL per bottle, and the dose is 2 tbsp. How many mL will the nurse give?
1 tbsp = 15 mL
2 tbsp = 30 mL
What is the brand name for atenolol?
Tenormin
A patient becomes agitated, confused, and tachycardic after surgery. What complication should the nurse suspect?
Hypoxia or delirium.