Exam 39: Prevention and Care of Skin Breakdown

The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx.The patient complains of pain at the site,and the site feels cooler than the areas immediately around the site.The nurse recognizes that this patient has developed

How does the skin defend the body? (Select all that apply.)

When skin layers adhere to the linens and deeper tissue layer move downward,________ damage occurs.

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing.Which of the following can be appropriately delegated to an unregulated care provider?

On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?

The nurse should consider culturing a wound when which one of the following situations occurs?

The nurse is caring for a patient who has had major abdominal surgery and is concerned about the possibility of dehiscence.During the assessment,the nurse assesses for which of the following contributing factors? (Select all that apply.)

The patient with a nasogastric (NG)tube in place may experience skin breakdown

Patients are at risk for developing pressure injuries on which areas of the body? (Select all that apply.)

The nurse prepares to irrigate the patient's wound.What is the primary reason for this procedure?

The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours.While turning the patient,to what should the nurse who is performing the assessment pay particular attention?

The healing ridge is composed of newly formed collagen,and the nurse can usually feel it along a healing wound.The nurse knows it is usually present directly under the suture line on days

A _______________ is a localized injury to the skin or underlying tissue,usually over a bony prominence,as a result of pressure,or pressure in combination with shear or friction.

What should the nurse do to re-establish the vacuum of the Hemovac system after emptying?

The nurse is in the process of irrigating the wound for a patient who has a large pressure injury on his buttock.How should the nurse proceed?

The nurse is aware that pressure injuries can occur (Select all that apply.)

What is an appropriate technique for the nurse to implement for drainage evacuation?

Healing by ________ intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

___________ are threads of wire or other materials used to sew body tissues together.

The nurse is explaining healing of a full-thickness wound to a patient.Which of the following phases should the nurse include in the explanation? (Select all that apply.)