- Intact skin with non-blanchable redness.
- Partial thickness skin loss with exposed dermis.
- Full thickness skin loss with visible adipose tissue, granulation tissue, and epibole.
- Full thickness skin loss with exposed bone or muscle.
Category: Fundamental of nursing
- Contact precautions.
- Droplet precautions.
- Airborne precautions.
- Standard precautions only.
- Discard the vial.
- Recap the needle immediately.
- Label the vial with the date and time opened, and store it appropriately.
- Cleanse the rubber stopper with alcohol after each use.
- Any abbreviations they know.
- Only abbreviations from the hospital's approved list.
- Abbreviations that are commonly understood.
- No abbreviations at all.
- Restoring fluid balance.
- Preventing complications.
- Promoting activity.
- Managing pain.
- Respiratory distress.
- Neurological deficits.
- Circulatory impairment.
- Gastrointestinal issues.
- A stiff toothbrush and abrasive toothpaste.
- A soft toothbrush or foam swab, and minimal fluid for rinsing.
- A large amount of mouthwash.
- Their gloved fingers to clean the mouth.
- Allow the student to continue and correct them later.
- Administer the medication themselves.
- Intervene and instruct the student to re-verify the patient's identity using two identifiers.
- Document the student's error.
- Reduce pain during injection.
- Prevent nerve injury.
- Ensure medication is injected into the subcutaneous tissue layer.
- Facilitate faster absorption.
- Pain characteristics, vital signs, and cardiac assessment.
- Family history of heart disease.
- Patient's dietary intake.
- Previous history of anxiety.
- Changing the topic to something less anxiety-provoking.
- Allowing the patient to continue rambling.
- Directing the conversation back to the main point or a specific concern.
- Giving advice on how to stop rambling.
- Nurse's preference.
- UAP's willingness.
- Scope of practice and patient acuity.
- Time availability.
- Patient satisfaction.
- Hospital efficiency.
- Patient safety.
- Legal compliance.
- Manual regulation of infusion.
- Precise and controlled medication delivery.
- Faster medication administration.
- Prevention of all IV complications.
- Apply petroleum jelly to the skin.
- Tighten the cannula straps firmly.
- Pad the tubing, regularly assess skin integrity, and ensure proper fit.
- Remove the cannula periodically.
- Non-pitting edema.
- 1+ pitting edema.
- 2+ pitting edema.
- 3+ pitting edema.
- Right to privacy.
- Right to informed consent.
- Right to refuse treatment.
- Right to information and safety.
- Subjective and objective data.
- Incomplete documentation.
- Only subjective data.
- Only objective data.
- Administering opioids.
- Applying heat or cold packs, distraction, or guided imagery.
- Sedating the patient.
- Ignoring the pain.
