Breathe!
This minimum flow rate should be maintained when using a simple face mask to prevent rebreathing carbon dioxide.
What is 5 L/min?
A patient’s Braden Scale score drops from 17 to 11. This change indicates the need for increased attention to this nursing priority.
What is pressure-injury prevention?
Edema surrounding a lower-leg wound is interfering with tissue repair. The nurse should address the edema by taking this action, when appropriate and not contraindicated.
What is elevate the limb?
Before making an SBAR call about a change in condition, the nurse should collect these current assessment findings.
What are vital signs, allergies, relevant laboratory results, and other pertinent patient data?
A stable patient who can clearly communicate needs requires routine hygiene care. The RN may delegate this task to which member of the healthcare team?
Who is trained assistive personnel?
When nasal-cannula tubing causes redness behind the ears, the nurse should take these actions while continuing the prescribed oxygen therapy.
What are pad the tubing, reposition it, and reassess the skin?
When assessing darkly pigmented skin for an early pressure injury, the nurse should evaluate for these findings instead of relying only on visible redness.
What are nonblanching color changes, temperature changes, firmness, swelling, and pain?
A patient who smokes asks why the wound is healing slowly. The nurse should explain that nicotine produces this effect on wound healing.
What is vasoconstriction that reduces oxygen delivery to healing tissue?
A patient has suprapubic pressure, has not voided for eight hours, and has a bladder-scan volume of 700 mL. The nurse should communicate this concern and request this action.
What is prompt evaluation and an order or protocol-directed intervention for urinary retention? (Straight cath)
A stable patient requires a routine daily weight before breakfast. The RN may delegate obtaining the weight but must retain responsibility for this action.
What is interpreting and responding to significant changes?
If a nonrebreather reservoir bag collapses during inspiration, the nurse should check these items and adjust the oxygen flow.
What are the oxygen source and connections, then increase the flow so the bag remains partially inflated?
A shallow, irregular area of skin loss results from prolonged urine exposure rather than pressure over a bony prominence. This finding is most consistent with this condition.
What is moisture-associated skin damage? (MASD)
A patient with a large wound eats very little and avoids protein-rich foods. The nurse should prioritize this intervention.
What is assess nutritional status and collaborate to improve protein, calorie, fluid, vitamin, and mineral intake?
When reporting a suspected medication reaction, the nurse should include these details about the newly administered medication.
What are the medication name, dose, time administered, allergies, and relevant previous reactions?
A stable patient has an established chronic-wound dressing order with no recent change in condition. The RN may assign the dressing change to this licensed team member when permitted by policy and scope of practice.
Who is a competent LPN/LVN?
This action is required when a blanket covers the air-entrainment ports of a Venturi-mask adapter.
What is uncover the ports immediately?
A patient has dry, firmly adherent heel eschar with no drainage, erythema, warmth, or fluctuance. The nurse should take this action.
What is leave the stable heel eschar intact and monitor it?
A foot wound is pale and cool, and pedal pulses are difficult to locate. These assessments should be prioritized before continuing routine wound care.
What are neurovascular and peripheral-perfusion assessments?
A provider says to “watch the patient,” but the nurse observes falling blood pressure and worsening lethargy. The nurse should respond by doing this.
What is restate the objective trend and make a specific recommendation with a clear time frame?
A newly admitted patient coughs and develops a wet voice whenever food is offered. The RN should assess for this.
What is aspiration risk?
A patient has an oxygen saturation of 96%, but is difficult to arouse with shallow respirations at 7/min. The nurse should recognize this priority concern.
What is inadequate ventilation requiring urgent intervention?
After slough is removed, a wound reveals adipose tissue and undermining without exposed muscle, tendon, cartilage, or bone. This finding identifies the injury as this stage.
What is a Stage 3 pressure injury?
A patient with diabetic neuropathy believes a foot wound is healing because it no longer hurts. The nurse should explain why absence of pain does not confirm healing.
What is neuropathy may reduce pain sensation, so the wound still requires direct assessment and pressure offloading?
A patient continues to deteriorate despite repeated unanswered SBAR calls. The nurse should escalate the situation through this process while continuing immediate care.
What is activate the chain of command or rapid-response process?
The RN delegates intake and output measurement to assistive personnel. The assistive personnel reports that the patient produced only 20 mL of urine during the past four hours. The RN must take this action.
What is assess the patient, validate the reported output, and promptly address the abnormal finding?