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The nurse is caring for an older adult client. Which commonly observed symptoms should the nurse monitor this client for first that may indicate infection?

The nurse is caring for an 86-year old client who is hearing impaired.  Which intervention should the nurse implement first?

The nurse is caring for a 68 year old wheelchair bound male who has come to the clinical with his daughter for a routine checkup. Nurses’ Notes:  1000: Client received for a routine checkup accompanied by daughter with whom he lives. Client has paraplegia secondary to spinal cord injury. Client is alert and oriented x4. Denies pain or any problems. Daughter is concerned about “red area on his left heel.”  VS 97.9F-76-16-112/68 Lungs clear, S1S2 audible with no murmurs, gallops, rubs. Bowel sounds hypoactive. Full range of motion in bilateral upper extremities with light touch sensation intact in fingers. No feeling or movement below waist. Full passive ROM bilaterally in lower extremities. Open area noted on left heel – foul odor detected. Skin otherwise intact.  1015: Left heel wound measures 3.5cmx4cmx1cm. No undermining present. Wound bed is pink with small area of white subcutaneous tissue noted. Sligh foul odor detected. No drainage noted. Skin surrounding injury pink, warm, and dry. Provider and wound nurse notified of wound. 

The nurse is caring for a 68 year old white wheelchair bound male who has come to the clinical with his daughter for a routine checkup. Nurses’ Notes:  1000: Client received for a routine checkup accompanied by daughter with whom he lives. Client has paraplegia secondary to spinal cord injury. Client is alert and oriented x4. Denies pain or any problems. Daughter is concerned about “red area on his left heel.”  VS 97.9F-76-16-112/68 Lungs clear, S1S2 audible with no murmurs, gallops, rubs. Bowel sounds hypoactive. Full range of motion in bilateral upper extremities with light touch sensation intact in fingers. No feeling or movement below waist. Full passive ROM bilaterally in lower extremities. Open area noted on left heel – foul odor detected. Skin otherwise intact.  Choose which findings indicate pressure injury, venous stasis ulcer, or both. 

When changing the dressing on a pressure ulcer, a nurse notes necrotic wound tissue that wasn’t noted during the previous dressing change.  What is the most appropriate nursing intervention?

The nurse is caring for a 68 year old wheelchair bound male who has come to the clinical with his daughter for a routine checkup. Nurses’ Notes:  1000: Client received for a routine checkup accompanied by daughter with whom he lives. Client has paraplegia secondary to spinal cord injury. Client is alert and oriented x4. Denies pain or any problems. Daughter is concerned about “red area on his left heel.”  VS 97.9F-76-16-112/68 Lungs clear, S1S2 audible with no murmurs, gallops, rubs. Bowel sounds hypoactive. Full range of motion in bilateral upper extremities with light touch sensation intact in fingers. No feeling or movement below waist. Full passive ROM bilaterally in lower extremities. Open area noted on left heel – foul odor detected. Skin otherwise intact.  Which 4 findings are of most concern to the nurse? Select those that apply.

The nurse has just completed discharge teaching for a client who has undergone cataract surgery.  What statement, by the client, alerts the nurse that further teaching is needed?

The nurse is caring for a 68 year old wheelchair bound male who has come to the clinical with his daughter for a routine checkup. Nurses’ Notes:  1000: Client received for a routine checkup accompanied by daughter with whom he lives. Client has paraplegia secondary to spinal cord injury. Client is alert and oriented x4. Denies pain or any problems. Daughter is concerned about “red area on his left heel.”  VS 97.9F-76-16-112/68 Lungs clear, S1S2 audible with no murmurs, gallops, rubs. Bowel sounds hypoactive. Full range of motion in bilateral upper extremities with light touch sensation intact in fingers. No feeling or movement below waist. Full passive ROM bilaterally in lower extremities. Open area noted on left heel – foul odor detected. Skin otherwise intact.  1015: Left heel wound measures 3.5cmx4c.x1cm. No undermining present. Wound bed is pink with small amount of white subcutaneous tissue noted. Slight foul odor detected. No drainage noted. Skin surrounding injury pink, warm, and dry. Provider and wound nurse notified of wound. 1030: Wound nurse here to assess left heel wound. Confirms stage III pressure injury.  New orders: Cleanse left heel with normal saline and complete wet to dry dressings every 6 hours. Return in two weeks for follow up. What 3 actions should the nurse tell the client and his daughter about wound care?

The nurse is planning care to prevent pressure ulcers in a client who is at high risk.  Which intervention is best for the nurse to perform?

What does the term “ventral” refer to?