Nsg 300 exam 2 stuvia - Study guides, Class notes & Summaries

what places patients at risk for pressure ulcers/impaired skin integrity -ANSWER pressure intensity, pressure duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in LOC, shear, friction, moisture layers of the skin -ANSWER epidermis, dermis (collagen) body's defenses against infection -ANSWER normal flora, inflammatory response, immune response comprehensive wound assessment -ANSWER -ongoing assessment from time of injury, wound care, any condition ch...

topic 4 objectives - ANSWER1. Examine the factors that place clients at risk for impaired skin integrity. 2. Apply the elements of a comprehensive wound assessment. 3. Utilize the planning component of the nursing process to demonstrate nurse's role and responsibilities for skin and wound care. 4. Determine nursing interventions that promote healing and the prevention of wound infections in clients with impaired skin integrity. layers of skin - ANSWERepidermis dermal-epidermal junctio...

Acute wounds -ANSWER Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical functional integrity Surgery or trauma Chronic wounds -ANSWER Wounds that fail to proceed through an orderly and timely process to produce anatomical and and functional integrity Vascular compromise and chronic inflammation Detecting internal bleeding -ANSWER Distention or swelling in the affected body part Change in the amount of drainage Signs...

B - ANSWERUnder no circumstances should what be administer by IV? a) Normal saline b) Potassium chloride c) Diuretics D) Protonix C - ANSWERWhat is the body's first line of defense against infection? a) sterile field b) Antibiotics c) Integ system d) Genitourinary system D - ANSWERThis can help promote wound healing: a) Braden scale b) Increased age c) Friction d) Therapeutic diet C - ANSWERThis item, placed on a client's bed, can help redistribute pressure: a) JP...