Exam 35: Skin Integrity Wound Healing

Which of the following are the two risk assessment tools most commonly used in the United States to evaluate a client's risk for pressure ulcers? Select all that apply.

Which of the following would be the most appropriate outcome for the client with a stage 2 pressure ulcer?

While applying a wet-to-dry dressing, how would the nurse explain to the client how this procedure works for promoting healing? A wet-to-dry dressing is a:

The nurse documents that the new wound has serosanguineous drainage. How is serosanguineous described?

A client hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. There is a pressure area on the client's coccyx measuring 5 *3 cm. The area is covered with 100% eschar. What would the nurse identify this as?

The nurse is assessing a client that has an underlying cardiac disease and a draining wound, all of which requires careful monitoring of his fluid balance. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?

The nurse assesses the surrounding skin of the client's colostomy. The client has been incorrectly applying his ostomy appliance and which caused a wound due to the continuous contact with liquid stool. The nurse notes bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound?

The nurse is preparing to apply cold therapy. Which of the following diagnoses are contraindicated for cold therapy?

The nurse is preparing to perform wound care for the client that has a stage 2 pressure ulcer on their right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound?

What type of wound can be described as a superficial wound, usually self-inflicted due to excessive scratching or mechanical force?

The nurse assesses assigned clients and determines which client is at highest risk for altered skin integrity?

The nurse is assessing the client with a wound that is considered chronic. The client asks the nurse to explain the difference between chronic and acute wounds. Which of the following would best describe the primary difference between chronic and acute?

The nurse is developing a plan of care for a client who was injured in a motor vehicle accident yesterday. The client is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time?

The nurse is developing a teaching plan for a client that has a surgical incision that has been left open. Which of the following points would the nurse make?

The nurse is reviewing a wound care nurse's narrative note that states there is a fistula in the lower abdominal wall as a result of a poorly healing surgical wound. What is a common cause of a fistula?

The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. There is a notation that states there is an absence of the stratum corneum. Which of the following explains why this is a concern?

Which of the following clients does the nurse recognize as being at greatest risk for pressure ulcers?

The nurse is assessing the client who presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?

Why is an accurate description of the location of a wound important? Select all that apply.

The nurse is caring for a client with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply?