Exam 48: Skin Integrity and Wound Care

The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?

A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?

A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take $\bold{next}$ ?

A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?

The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?

The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.)

The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?

The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.)

The nurse is caring for a surgical patient. Which intervention is $\bold{most}$ important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?

The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse $\bold{most}$ likely increase after collaboration with the dietitian?

The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the $\bold{priority}$ ?

The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing?

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which $\bold{next}$ step will the nurse anticipate?

The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.)