Basic Care and Comfort

3 free questions

• During a skin assessment of a client who is immobile, the nurse finds an open area over the sacrum with full-thickness skin loss. Subcutaneous fat is visible, and yellow slough covers part of the wound bed, but the depth of the wound can be seen. No bone, tendon, or muscle is visible or palpable. How should the nurse document this wound?
• The nurse is caring for an adult client receiving a continuous feeding through a nasogastric tube; tube placement was confirmed by radiograph when the tube was inserted. Which actions are appropriate? Select all that apply.
• A client with advanced dementia who cannot reliably report pain had surgical repair of a hip fracture yesterday. Which approach should the nurse use to assess the client's pain?