Exam 35: Skin Integrity Wound Healing

A client developed a stage 4 pressure ulcer in his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply.

The nurse is providing care to the client that has experienced extensive third-degree burns. The nurse is aware that this client will have what type of healing?

The nurse is developing plan of care for the client with a stage 4 pressure ulcer, what would an applicable client goal/outcome be?

Which of the following are examples of nonselective mechanical debridement methods? Select all that apply.

A client underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:

The nurse admits an older adult client to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment?

The nurse is preparing to perform a wound irrigation. Which of the following is the best choice for performing wound irrigation?

An adult client is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The client has no problem with rubbing, friction, or shear. What is the Braden score for this client?

The nurse is preparing to provide care to the client who has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing?

The nurse is preparing to apply heat therapy alternated with cold therapy to a wound. What is the proper method for this therapy?

The nurse in the emergency department admits a client with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing?

The nurse learns in report that the assigned client has a stage 3 pressure ulcer. What type of tissue does the nurse expect to visualize in the wound? Select all that apply.

The client is status post abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following?

The nurse obtains a swab culture from a chronic wound and understands that this may have limited findings. Why is the information obtained from a swab culture of a wound limited?

The nurse is assessing the client's wound and notes that the wound bed shows granulation. What phase of wound healing is described by the nurse's note?

The nurse is providing care to the client who is 2 days status post cerebrovascular accident with residual decreased left-sided mobility. During the assessment, the nurse discovers a stage 1 pressure area on the client's left heel. What is the initial treatment for this pressure ulcer?

A client has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage 1 pressure ulcer. What would be the most important treatment for this client?

The client has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound?

Which actions would the nurse take when emptying the client's closed-wound drainage system? Select all that apply.