Exam 39: Prevention and Care of Skin Breakdown

___________ is black,brown,or tan tissue in the wound that should be removed before wound healing can begin.

The nurse is caring for a patient who has a dressing over a surgical wound created the night before.The dressing has never been changed.How should the nurse proceed?

Which of the following approaches is correct technique when wound irrigation is performed?

A nurse classifies a pressure ulcer according to the type of tissue in the wound bed.What does it indicate if the wound bed has granulation in it?

_____________ uses the mechanical force (high or low)of a stream of solution to remove debris,bacteria,and necrotic tissue from a wound.

The nurse is explaining wound healing to a patient.Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound?

The removal of devitalized tissue in a wound is known as ______________.

The physician expects that the patient's wound will have an output of close to 500 mL/day.The nurse anticipates placement of which of the following?

Healing by primary intention is expected to occur with which of the following situations?

What should the nurse do when performing suture or staple removal?

The nurse is caring for four patients during a shift.Which of the following patients is at greatest risk for developing a pressure injury?

A patient with anemia is at risk for developing pressure injuries as a result of which of the following?

The nurse is educating a patient about his role in wound healing.Which of the following factors,if modified by the patient,can support adequate oxygenation at the tissue level?

In a long-term care facility,how often should the nurse reassess a patient for risk of a pressure ulcer?

Wounds that have been approved for treatment using negative-pressure wound therapy (NPWT)include which of the following? (Select all that apply.)

The nurse is explaining negative-pressure wound therapy (NPWT)to a patient.Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.)

The Jackson-Pratt (JP)drain relies on the presence of a vacuum to withdraw drainage and is considered a(n)__________ drainage system.

When evaluating a patient,the nurse observes an unexpected outcome of treatment when the surrounding skin of a pressure injury becomes macerated.The nurse should

After teaching a home caregiver how to manage a pressure ulcer,the nurse realizes that further education is needed when the caregiver says:

When teaching about wound care in the home environment,the nurse instructs the patient and caregiver to