Exam 29: Skin Integrity and Wound Care

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions will the nurse perform?

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a "popping sensation" and a wetness in the dressing, the nurse immediately suspects which complication?

The nurse recognizes which intervention is not a form of mechanical debridement?

The nurse knows which description would be classified as a closed wound?

The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding?

The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?

The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility?

The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for further education?

The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?

The nurse recognizes that the cause of pressure ulcers includes which factors?

The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?

The nurse identifies which syringe to use when irrigating a patient's deep wound?

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first?

When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?

The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing?

When the nurse is performing a focused wound assessment on a patient, what information should be included in the documentation?

The nurse understands which rationale to be appropriate for drying a wound after irrigation?

A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?

The nurse is using the Braden scale to assess the patient's risk for a pressure ulcer. Which risk categories are associated with the Braden scale?