TISSUE INTEGRITY
A nurse assesses a pressure area that appears red but turns white when pressed. What does this finding indicate?
what is Blanchable erythema (not a pressure injury yet)
A nurse instructs a postoperative client to perform leg exercises every 1–2 hours. This is to prevent this surgical complication.
What is Deep vein thrombosis (DVT)
This hormone produced by the pineal gland helps regulate the body’s sleep-wake cycle and prepares the body for sleep.
What is melatonin
A nurse is assessing a wound and observes thick yellow drainage with a foul odor coming from the incision site. This type of drainage indicates this complication.
What is infection
This skin condition occurs when the skin is exposed to urine, feces, wound drainage, or sweat, causing irritation, redness, burning, and itching.
What is Moisture-associated skin damage (MASD)
A client with urinary incontinence develops skin irritation due to prolonged exposure to moisture, resulting in soft, overhydrated tissue.
What is Maceration
A nurse reviewing a preoperative history notes that a client smokes cigarettes daily. This habit increases the client’s risk for postoperative complications especially this one
What is Blood clots
This stage of sleep is the lightest stage, lasts about 1–5 minutes, and occurs when a person first becomes drowsy and closes their eyes.
What is Stage 1 sleep
A nurse is caring for a client who has a Penrose drain following abdominal surgery. The nurse notices drainage leaking onto the dressing around the drain site. Because this drain does not have a collection chamber, the nurse should collect drainage using this item.
What is a sterile gauze dressing (perforated 4 × 4 gauze)
This local factor delays wound healing by creating a thick grouping of microorganisms that protects bacteria from treatment.
What is Biofilm
A nurse is assessing a wound and notes clear fluid mixed with small amounts of blood on the dressing. It's slightly pink in color which is a indication of this type of drainage.
What is serosanguineous drainage
This postoperative pain management device is a computerized pump connected to an IV that allows the client to self-administer small doses of analgesic medication by pressing a button.
What is a patient-controlled analgesia (PCA) pump
This stage of sleep accounts for about 50% of the sleep cycle and is characterized by sleep spindles and K-complex brain waves.
What is Stage 2 sleep
A nurse is assessing a postoperative client who begins coughing suddenly. The nurse notices that the surgical incision has separated, and shortly afterward abdominal organs begin protruding through the open wound an (evisceration). This complication occurs from a result of a surgical wound that opened from this other complication
what is dehiscence
This complication occurs when blood collects under a surgical incision, often related to anticoagulant therapy or early drain removal.
What is a Hematoma
A nurse is caring for a client at risk for pressure injury and positions the client on their side. This is the recommended body tilt angle to reduce pressure and shear
What is 30 Degrees
A nurse teaches a postoperative client to use this device 10 times every hour while awake to help expand the lungs and prevent atelectasis.
What is an incentive spirometer
During this stage of sleep, delta brain waves occur, and the body performs tissue repair and immune system strengthening
What is Stage 3 sleep
A nurse is irrigating a client’s wound using sterile technique. The nurse continues flushing the wound with normal saline. The nurse should continue irrigation until this occurs.
What is the drainage runs clear
A nurse instructs a postoperative client to turn, cough, and breathe deeply and use an incentive spirometer every hour while awake to prevent this complication.
What is Atelectasis
A nurse is assessing a client with delayed wound healing. This systemic factor most directly impairs tissue oxygenation and collagen formation, increasing the risk for tissue breakdown
What is poor circulation
Before surgery, the nurse must verify that this process has occurred, ensuring the provider explained the procedure, risks, benefits, and alternatives and that the client is competent to sign
What is informed consent
A critically ill client becomes restless, anxious, and confused due to excessive noise, lights, alarms, and frequent care interruptions. This condition occurs when the brain cannot process stimuli at a meaningful rate.
What is sensory overload
A nurse is assessing a client who had abdominal surgery two days ago. The nurse previously noted purulent drainage with a foul odor at the incision site. During reassessment, the client now has tachycardia, fever, confusion, and hypotension. The nurse recognizes these findings indicate that the localized surgical infection may be spreading into the bloodstream, leading to this life-threatening complication.
What is sepsis
This condition occurs when stimuli overwhelm the brain’s ability to process information, causing anxiety, restlessness, and confusion.
What is Sensory overload