Integumentary System
A nurse is performing wound care during the acute/intermediate phase of burn care, to prevent infection, this would be the most IMPORTANT action...
What is using barrier techniques such as gowns/gloves?
The patient has a fractured femur and has begun to show early signs of fat embolism syndrome. This neurological sign would show this....
What is Confusion?
A 45yo patient recently dx with Guillain-Barre Syndrome. They are presenting with weakness in the LE that's progressed to the UE. Patient reporting paresthesia in hands and feet.
This would be the priority complication for the nurse to monitor for...
What is Respiratory Failure?
A patient scheduled for an Upper GI fluoroscopy using barium needs pre-procedure education. This would be the MOST important instruction for the nurse to give...
What is-to refrain from smoking or chewing gum after midnight before the procedure?
A burn injury to the left forearm with blisters over a mottled red base and a weeping surface would be classified as this burn depth...
What is a Second-Degree burn (or partial thickness)?
Your client is 24hrs post-op for a total hip arthroplasty and should avoid this type sitting to prevent hip dislocation...
What is Adduction?
This nursing intervention would be MOST appropriate for optimizing cerebral tissue perfusion in a patient with increased ICP..
What is maintaining the patient's head in a neutral midline position?
An older adult client reports a hx of occasional dysphagia and dyspepsia, based on this and the gerontologic changes in the GI system, this would be the most relevant nursing assessment..
What is inspecting the oral cavity for lesions or other abnormalities?
An 82yo patient with a hx of COPD sustained a 20% TBSA flame burn. Due to the gerontologic considerations, hx of COPD, the patient would be at increased risk for this.. compared to a younger adult with similar burns..
What is increased likelihood of mortality?
As a nurse caring for a patient with osteoporosis giving dietary recommendations of foods with these items...
What is calcium and Vitamin D?
This nursing action would be MOST important for a patient with Creutzfeldt-Jakob Disease who is receiving palliative care...
What is preventing injury related to immobility and dementia?
A patient is scheduled for a colonoscopy an requires adequate bowel prep for the procedure to be successful. A statement from the patient indicating the need for further education would be...
What is "I will continue taking my aspirin or NSAIDs up unitl the day of the procedure"?
A patient with circumferential full-thickness burns of the lower leg develops increasing pain, pallor, and loss of dorsalis pedis pulse in affected extremity. This is the most likely cause of immediate complication...
What is acute compartment syndrome?
With skeletal traction, you would report this finding immediately..
What is delayed capillary refill?
A patient with increased ICP is prescribed an osmotic diuretic, mannitol. When making a care plan for the patient, This nursing intervention is MOST important to include...
What is monitoring the patient's serum osmolality and electrolytes?
This nursing intervention would take the highest priority following an EGD with moderate sedation...
What is the assessment of gag reflex return before allowing oral intake?
During the emergent/resuscitative phase of burn care, the IV fluid of choice according to the American Burn Association is this...
What is Lactated Ringers (LR)?
What is heat, or warm compresses?
A patient in the hospital begins experiencing a general tonic-clonic seizure. This would be the highest priority nursing action..
What is protecting the patient's head from injury?
The nurse would explain THIS with a positive FIT test result
What is the need for further diagnostic testing such as a colonoscopy?