The nurse changes the dressing of the patient with a sacral pressure injury. Upon removal of the dressing, the nurse notes yellow drainage on the dressing with a fruity odor. Place the nurse’s actions in the correct order from first to last.

  • Cleanse the wound with tap water
  • Discard the dressing after noting amount of drainage
  • Take cultures of the center of the wound
  • Assess for further signs of infection in the wound

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Additional Physiological Adaptation Questions

A patient in the ICU following a motor vehicle accident has been intubated for 72 hours. Over the previous 12 hours, the patient’s oxygen requirement has increased, tidal volumes have decreased, and the patient’s endotracheal secretions have increased in quantity, thickness, and the color has changed from cloudy to green. The patient’s lab values are significant for a worsening respiratory acidosis and leukocytosis. Which diagnosis is most appropriate for this patient?

  • Question Type:   Multiple Choice - Select One
  • Difficulty: 4

The 75-year-old patient presents to the emergency department complaining of a severe headache that is localized behind the right eye. The patient is nauseous and vomits upon standing. While wearing glasses, the visual acuity is 20/25 in the left eye and 20/110 in the right (records show it is normally also 20/25 corrected). Her left pupil is equal, round, and reactive to light and accommodation; it is measured at 3 mm. Her right pupil reacts only minimally to light and measures at 5 mm; it is round. The provider palpates the eye and reports that it is tense. Her heart rate is 102 bpm and blood pressure is 118/84 mmHg. The nurse anticipates providing which intervention first?  

  • Question Type:   Multiple Choice - Select One
  • Difficulty: 10

The nurse learns that a patient is suspected to have a lysosomal storage disease. The nurse prepares to assist with testing for which disease(s)? Select all that apply.

  • Question Type:   Multiple Choice - Select All
  • Difficulty: 7

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