A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

A. Evidence-based practice:

Evidence-based practice (EBP) involves integrating the best available evidence from research, clinical expertise, and patient preferences and values to inform nursing practice. In perioperative nursing, EBP is important for making informed decisions about preoperative, intraoperative, and postoperative care protocols. For example, using evidence-based guidelines for surgical site infection prevention, pain management strategies, and postoperative care protocols can improve patient outcomes and safety.

B. Informatics:

Informatics refers to the use of information technology and data management systems to support nursing practice, education, research, and patient care. In perioperative nursing, informatics plays a crucial role in managing electronic health records (EHRs), accessing patient data, documenting care, and communicating with interdisciplinary team members. It also includes utilizing perioperative information systems for surgical scheduling, anesthesia records, and tracking patient progress during surgery.

C. Quality improvement:

Quality improvement (QI) involves systematic processes to monitor, assess, and improve the quality of healthcare services. In perioperative nursing, QI initiatives focus on enhancing patient safety, optimizing surgical outcomes, reducing complications, and improving efficiency in perioperative processes. Nurses participate in QI projects by analyzing data, identifying areas for improvement, implementing evidence-based practices, and evaluating the impact of interventions on patient care and outcomes.

D. Safety:

Safety is a fundamental QSEN competency, particularly critical in perioperative nursing care. Perioperative nurses are responsible for ensuring the safety of patients during all phases of surgery, including preoperative assessment, intraoperative care, and postoperative recovery. This includes measures such as verifying patient identity and surgical site, preventing surgical errors (e.g., wrong-site surgery), maintaining aseptic techniques to prevent infections, preventing falls and injuries, managing anesthesia safely, and adhering to protocols for safe medication administration and equipment use.

A. Excessive scarring:

Excessive scarring is not an example of a first-degree burn. It typically occurs in more severe burns that affect deeper layers of the skin, such as second-degree or third-degree burns. Second-degree burns extend into the dermis, while third-degree burns damage all layers of the skin and can lead to significant scarring. First-degree burns, on the other hand, only affect the outer layer of the skin (epidermis) and usually do not result in excessive scarring.

B. Blistering from flames:

Blistering from flames is more characteristic of a second-degree burn rather than a first-degree burn. Second-degree burns involve damage to both the epidermis and part of the dermis, which can result in blister formation. These burns are often caused by direct contact with flames, hot liquids, or steam.

C. Blackened dead skin:

Blackened dead skin is indicative of a third-degree burn, which is the most severe type of burn. Third-degree burns damage all layers of the skin, including the epidermis, dermis, and sometimes underlying tissues. The skin may appear charred or blackened, and these burns often require medical intervention, such as skin grafting, due to the extent of tissue damage.

D. A sunburn:

A sunburn is an example of a first-degree burn. It occurs due to overexposure to ultraviolet (UV) radiation from the sun, leading to redness, pain, and mild swelling of the skin. First-degree burns affect only the outer layer of the skin (epidermis) and typically heal within a few days without significant scarring or blistering. Applying soothing lotions, staying hydrated, and avoiding further sun exposure can help manage sunburns.