Skip to ContentGo to accessibility page
OpenStax Logo
Clinical Nursing Skills

What Should the Nurse Do?

Clinical Nursing SkillsWhat Should the Nurse Do?

What Should the Nurse Do?

The nurse on an intensive care unit is caring for an 83-year-old female admitted for a urinary tract infection and sepsis. The patient has been in a nursing home following a cerebrovascular accident resulting in right-sided weakness and paresthesia. The patient appears to be malnourished with sunken skin over bony prominences. During the shift assessment, the nurse notes a reddened area of intact, nonblanchable skin on the sacral areas. The head of the bed is elevated because the patient is at risk of aspiration with feedings.
1 .
How should the nurse assess the skin?
2 .
What factors increase this patient’s risk of skin breakdown?
3 .
What things can the nurse do to prevent further damage and promote healing?
4 .
You are caring for a patient who is recovering from a laparotomy surgery. The patient has been coughing all morning. The patient states that it “feels like something has come undone.” Upon examination you see that a section of the surgical incision has come apart. What should you do?
A patient is brought to the emergency department by ambulance at 7 p.m., approximately an hour after a house fire. The patient has second- and third-degree burns on their left side, including the left side of their head, their left arm and leg, and left torso and back. The nurse and receiving physician agree that the TBSA of the patient’s burn is 49.5 percent. The patient received 1,000 mL of lactated Ringer’s in the ambulance. The patient weighs 141 lb (64 kg). Using the Parkland burn formula, answer the following question about what the nurse should do.
5 .
How much fluid and what type of fluid should the nurse give the patient in the first twenty-four hours?
6 .
How much more fluid and at what rate should the nurse give the patient over the next seven hours?
PreviousNext
Order a print copy
Citation/Attribution
Reuse and redistribution of this content in digital or print format:
  • This book may not be used in the training of large language models or otherwise be ingested into large language models or generative AI offerings without OpenStax's prior written permission.
  • This book uses the Creative Commons Attribution-NonCommercial-ShareAlike License, which means that you can reuse and modify the material only for noncommercial purposes, must attribute OpenStax, and must distribute any derivative works under the same license.
  • Any commercial printing of this textbook, including using a local or custom printer, must be approved by OpenStax, and proper citation provided.
  • OpenStax-copyrighted images, activities, assessments, and similar components of this book are subject to the same licensing – CC-BY-NC-SA. They can be used for noncommercial purposes with attribution. Commercial use requires permission.
  • Permission requests: Anyone who intends to incorporate this content (including text, images, and other components) into large language models, use it in AI offerings, use it commercially (including in print), and/or has questions about another use case is welcome to complete our reuse request form.
Attribution information
  • If you are redistributing all or part of this book in a noncommercial print format, then you must include on every physical page the following attribution:

    Access for free at https://openstax.org/books/clinical-nursing-skills/pages/1-introduction

  • If you are redistributing all or part of this book in a noncommercial digital format, then for every page that includes OpenStax content, you must license the derivative work under the same CC-BY-NC-SA license as the original, and include on every digital page view the following attribution:

    Access for free at https://openstax.org/books/clinical-nursing-skills/pages/1-introduction

Citation information

The information below includes the information needed to generate citations in most major styles (APA, MLA, etc.); you must reformat and organize the information as needed to fit the requirements of the style. Use the information below to generate a citation. We recommend using a citation tool such as this one.

© Jul 23, 2026 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo, and Rice University name, and Rice University logo trademarks, or wordmarks are not subject to the Creative Commons license and may not be reproduced without the prior and express written consent of Rice University.