Exam 29: Skin Integrity and Wound Care

The nurse knows that mechanical debridement involves all of the following except:

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. The patient complains of a "popping sensation" and a wetness in her dressing. The nurse immediately suspects:

The nurse knows an appropriate goal for a patient with a stage III pressure ulcer with the nursing diagnosis Impaired physical mobility is:

The nurse knows to irrigate a deep wound with:

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

The nurse is delegating care of a patient with a chronic nonsterile wound to a UAP. The delegation is inappropriate if:

The nurse knows a stage III pressure ulcer is:

The nurse is performing a focused wound assessment on a patient. The following should be included in the documentation: (Select all that apply.)

The nurse knows that a hydrocolloid dressing is appropriate for the following type of wound:

The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a nursing diagnosis of Impaired skin integrity is:

The nurse knows the following wound would be classified as a closed wound:

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

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

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? (Select all that apply.)

The nurse knows that the cause of pressure ulcers includes the following factors: (Select all that apply.)

The nurse understands the rationale for drying a wound after irrigation is:

The nurse knows that cold therapy is contraindicated in the following conditions: (Select all that apply.)

The nurse knows the following types of wounds heal by tertiary intention:

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

The nurse knows that the following factors contribute to the development of wounds and lead to delays in wound healing: (Select all that apply.)