Exam 31: Performing Wound and Pressure Ulcer Care

For which client would the nurse consider applying a transparent film for wound care?

The nurse is performing a damp-to-damp dressing change,and is removing the old dressing.Part of the dressing is adhered to the tissue.Which action by the nurse is the most appropriate?

When the nurse documents a client's wound,which is the best means of describing the wound?

When assessing a client with a new contaminated wound,which is the most important factor for the nurse to assess?

The nurse is changing the client's dressing on a postoperative nondraining wound.Which personal protective equipment (PPE)would the nurse don prior to the dressing change?

The nurse is applying a hydrocolloid dressing to a client's wound,which measures 2 inches by 3 inches.The nurse would cut the dressing to which dimensions?

Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

The nurse is assessing the client for pressure ulcer risk.The client has no sensory deficits,and the skin is dry and not exposed to moisture.The client is,however,confined to bed and is completely immobile and requires moderate assistance in moving.The client's nutritional status is adequate.Which score documented by the nurse is the most appropriate based on the assessment data?

The nurse is admitting a client with a pressure ulcer to the long-term care facility.When assessing the wound,the nurse finds partial-thickness skin loss free of eschar.Which stage will the nurse document this ulcer as based on the assessment data?

The nurse is bandaging the client's right knee.Where does the nurse begin the bandage?

The nurse is irrigating a wound with tracts and crevices,and applies which piece of equipment to the syringe in order to irrigate these areas?

The nurse is assisting the client with a sitz bath,and would perform which steps?

The client experiences a burn on the arm that is confined to the skin.How would the nurse describe this burn when documenting this client's care?

The nurse changes the client's IV dressing and removes the existing transparent wound barrier.Prior to applying the new barrier,which action by the nurse is the most appropriate?

The nurse notes black necrotic tissue on the client's wound.Which term is appropriate for the nurse to use when documenting this finding?

The nurse is preparing to assess a wound on a new admission on a medical-surgical unit.Which items should the nurse review in the medical record prior to assessing the client's wound?