-
a person has a laceration on the right leg from a fall. the wound is
open, unintentional & contaminated
-
a person had a rectal surgery. the person has a
clean contaminated wound
-
skin & underlying tissue are pierced. this is
a penetrating wound
-
which can cause skin tears
wearing rings
-
person has circulatory ulcer. which measure should you question
hold socks in place with elastic garters
-
elastic stockings prevent
prevent blood clots
-
elastic stocking are applied
before the person gets out of bed
-
when applying an elastic bandage
position the part in good alignment
-
person with diabetes are at risk for diabetic foot ulcers because of
nerve and blood vessel damage
-
A person has diabetes you should check the persons feet every
day
-
A person with diabetes needs to wear socks with shoes to prevent
blisters
-
a wound is separating this is called
dehiscene
-
clear watery drainage from a wound is called
serous drainage
-
a dressing does the following except
support the wound & reduce swelling
-
to secure a dressing apply tape
to the top, middle & bottom of the dressing
-
a person has frequent dressing changes. the nurse will likely have the dressing secured with
montgomery ties
-
a person receives a pain-relief drug before dressing change. how long should you wait for the drug to take effect
30 minutes
-
to remove tape
pull it toward the wound
-
an abdominal binder is used to
provide support and hold dressings in place
-
Heat applications have these effects except
decreased blood flow
-
the greatest threat from heat application is
burns
-
Which statement about moist heat applications is false
the effects of moist heat are less than from dry heat application
-
a hot application is usually
98-106 F
-
Which statement about sitz baths are false
sitz baths last 25-30 minutes
-
a person uses an aquathermia pad. which statement is false
pins secure the pad in place
-
cold applications reduce
reduce pain, prevent swelling and decrease circulation
-
Which isn't a complication of cold applications
infection
-
before applying an ice bag
place the bag in a cover
-
a pressure ulcer is
a localized injury to the skin and or underlying tissue
-
pressure ulcers are the result of
unrelieved pressure
-
which of the following contribute to the development of pressure ulcers
shear and friction
-
a pressure ulcer can develop within
2-6hrs
-
the following are risk factors for pressure ulcers except
balanced diet
-
which is the most common site for pressure ulcer
sacrum
-
in a light-skinned person the 1st sign of a pressure ulcer is
a reddened area
-
a persons care plan includes the following, which should you u question
scrub & rub the skin during bathing
-
when positioning a person you should position the person
using assist devices
-
what is the preferred position for preventing pressure ulcers
30 degree lateral position
-
besides heel and foot elevators, which are used to keep the heels and ankles off the bed
pillows
-
persons sitting in a chair should shift every
15 minutes
-
a person sitting in a chair their feet don't touch the floor. What should you do
position the feet on a foot rest
-
Which arent used to treat pressure ulcers
plastic drawsheets & waterproof pads
-
the following are sources of moisture except
barrier ointment
-
u see a reddened area on a person skin what should you do
tell the nurse
-
the nurse tells you that the persons pressure ulcer is colonized. this means
bacteria are present
-
t/f: all pressure ulcers are avoidable
false
-
skin breakdown can lead to pressure ulcers T/F
TRUE
-
T/F: unrelieved pressure squeezes tiny blood vessels. tissue doesnt receive needed oxygen and nutrients
true
-
t/f: persons who r bedfast or chairfast are at risk for pressure ulcers
true
-
t/f: pressure ulcers can develop on the ears
true
-
t/f: pressure ulcers can develop where medical devices are attached to the skin
true
-
t/f: you are responsible for identifying persons at risk for pressure ulcers
false
-
t/f: person has a don't resuscitate order. this means that the person is refusing treatment for a pressure ulcer
false
-
t/f: u use the resident assessment instrument to assess a persons risk factorand skin condition
fasle
-
t/f: pressure ulcers can involve muscles, tendons, and bones
true
-
t/f: to prevent pressure ulcers the head of the bed is raised higher than 30 degrees
false
-
t/f: u should inspect the persons skin every time you provide care
true
-
t/f: person is at risk for presure ulcers. a bath is needed every day
false
-
t/f: u are giving a back massage u should massage bony areas
false
-
t/f: u can use pillows and blankets to prevent skin from being in contact with skin
true
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