2024 Hondros NUR150 Exam 2 100% SOLUTION

Used to treat inflammatory responses- decreases edema, muscle spasms, pain, and decreases blood flow to the area. - ANSWER Cold and Heat Therapy when is cold and heat therapy recommended for an injury - ANSWER first 24 to 48 hours whose responsibility is it to evaluate proper application, adverse signs and symptoms and is also responsible for the patient's safety - ANSWER LPN where should you not apply a cold pack to - ANSWER red or blue areas how often should you check the skin of a patient who is using an electrical cooling device or an electrical heating device - ANSWER every 5 minutes what are common symptoms when using an electrical cooling device - ANSWER numbness and tingling How long should you leave a cooling device in place - ANSWER 15 to 20 minutes what are some adverse skin reactions when using a cooling device - ANSWER mottling, redness, burning, blistering and numbness what should you record when using a cooling device or heating device - ANSWER what device you used, location, duration, patient response, patient teaching and patients response to teaching when should you immediately stop application of a cooling device - ANSWER areas become mottled, red or blue/purple, or if the patient Is complaining of pain/numbness when should you immediately stop application of a heating device - ANSWER skin becomes reddened and sensitive to touch, extreme warmth noted at the area, and body part becomes painful to move How long should you leave the heating device in place - ANSWER 20 to 30 minutes or as prescribed whose responsibility is it to assess skin areas prior to applications of heating and cooling device and assess for risks - ANSWER LPN what is one of the nurse's highest priority of care - ANSWER prevention and treatment of skin impairment how often should you reposition a chair bound patient - ANSWER every hour how often should you reposition a patient that is bed bound - ANSWER every 2 hours at a 30 degree angle whose responsibility is it to properly collect a culture of the pressure ulcer - ANSWER nurse how do you properly label a specimen - ANSWER patients name, medical record number, date of birth, date and time of collection, what the collection is for, your name and initials. send as quickly as possible to the lab what are anaerobic collections of - ANSWER inside of body cavities what are aerobic collections of - ANSWER wound secretions occurs when the tissue layers of skin slide on each other , causing subcutaneous blood vessels to kink or stretch resulting in an interruption of blood flow to the skin - ANSWER shearing force the rubbing of skin against another surface produces what - ANSWER friction what are the 2 mechanical factors that play a common role in the development of pressure ulcers - ANSWER shearing force and friction which patients are at risk for pressure ulcers - ANSWER chronically ill, debilitated, older, disabled, or incontinent patients, patients with spinal cord injuries, circulatory impairment or poor overall nutrition how can the nurse assess a patients skin for skin impairment - ANSWER blanching the area a pressure ulcer in a localized area of skin, typically over a bony prominence , that is intact with nonblanchable redness. Areas may be painful, firm, soft, warm or cool compared with adjacent tissue. difficult to detect in patients with dark skin tones - ANSWER Stage 1 partial thickness loss of dermis. shallow open ulcer, usually shiny or dry, with a red-pink wound bed without slough or bruising. some may present as serum- filled blisters - ANSWER Stage 2 full tissue thickness loss in which subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed. if slough is present it does not obscure the depth of tissue loss. possible undermining and tunneling - ANSWER Stage 3 full thickness loss with exposed bone, tendon, or muscle. sometimes slough or eschar is present on some parts of the wound. Includes undermining and tunneling. - ANSWER Stage 4 which stage of pressure ulcer would put a patient at risk for osteomyelitis - ANSWER stage 4 pressure ulcer the true depth and stage of this ulcer can not be determined. wound bed is covered by slough this is yellow, tan, gray, green or brown. eschar wound bed is tan, brown or black. stable eschar on the heels provide a natural biologic cover. DO NOT REMOVE IT! - ANSWER unstageable/unclassified the wound appears as a localized purple or maroon area of discolored intact skin or a blood filled blister. painful, firm, mushy, boggy, or warm to cool compared with adjacent tissue. the wound is sometimes covered in thin eschar - ANSWER suspected deep tissue injury If chair bound patients are able to adjust their weight how often should they change their position - ANSWER every 15 minutes interventions for someone with a pressure ulcer - ANSWER nutrition ( protiens and vitamin c), oral intake teachings, repositioning of the patient every 2 hours in a 30 degree lateral-incline position. intact without abrasions, warm and moist, localized changes in texture across surface, good turgor (elastic and firm), generally smooth and soft - ANSWER characteristics of normal skin what should sputum not be mixed with during the specimen collection - ANSWER saliva a laboratory test involving cultivation of microorganisms or cells in a special growth medium - ANSWER culture