ooozy juice
A nurse is caring for a client who is immobile and incontinent. Which action is the most effective to prevent pressure injury formation?
Frequent repositioning and maintaining clean, dry skin are key preventive actions.
This soft, open drain uses gravity to remove excess fluid and is often secured with a safety pin.
Penrose drain
This dressing type adds moisture to a dry or necrotic wound to promote autolytic debridement.
Hydrogel
This is a single-lumen tube is used for intermittent suction, irrigation, or short-term feeding.
Levin tube
This is the most accurate method for confirming correct NG tube placement before the first use
X-ray confirmation
Which client is at the highest risk for developing a pressure injury?
One thats on a vent, immobile, leg injury
The nurse notices the bulb of a Jackson-Pratt drain is fully expanded. What should the nurse do?
What is compress the bulb and seal the plug to restore suction?
The nurse cleans a wound from the center outward using a new gauze for each stroke. This technique prevents what complication?
What is infection or cross-contamination?
This double-lumen tube includes a blue pigtail”€ air vent that prevents the stomach mucosa from being sucked into the tube.
Salem sump
The nurse should place the patient in this position during and after enteral feedings to reduce aspiration risk.
Semi fowler or high fowler
Which assessment finding indicates a Stage 2 pressure injury?
Partial-thickness skin loss with a pink, moist wound bed
After emptying a Hemovac drain, what should the nurse do before replacing the cap?
What is compress the spring to re-establish suction?
The nurse observes red, moist tissue in a wound bed. What does this indicate?
What is healthy granulation and healing tissue?
This NG tube is most commonly used for gastric decompression following abdominal surgery.
Salem sump
bonus: why
Before administering medications or feedings, the nurse should always check this to ensure the stomach is emptying properly.
gastric residual volume (GRV)?
A nurse observes a wound with full-thickness skin loss and visible fat tissue. How should this be staged?
Stage 3
This wound therapy applies continuous suction over a sealed foam dressing to remove exudate and promote granulation tissue.
What is Negative Pressure Wound Therapy (VAC)
The nurse finds yellow slough covering the wound bed. What action should be taken next?
prepare the wound for debridement per order
This feeding tube is smaller in diameter and designed to reduce reflux and aspiration risk by passing into the duodenum or jejunum.
Dobhoff or small-bore feeding tube
This intervention is performed before and after feedings, medication administration, and residual checks to maintain tube patency.
flushing the tube with sterile or tap water (per policy)
A client has a deep purple area over the heel that is intact and non-blanchable. Which stage of pressure injury should the nurse suspect?
Deep tissue injury (DTI)
During wound VAC therapy, the nurse notices bright red blood in the tubing. What is the priority action?
What is stop the suction and notify the provider immediately?
A client with a draining wound asks, Why cant I just leave the wound open to air? What is the best nursing response?
a moist environment promotes faster healing and prevents infection
This type of tube is sometimes used for lavage (washing out the stomach) in emergencies, such as drug overdose or poisoning.
an Ewald or large-bore orogastric tube
During NG tube removal, the nurse should instruct the patient to do this to prevent aspiration.
hold their breath (or exhale) while the tube is withdrawn