Exam 48: Skin Integrity and Wound Care

The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one? 1) Apply sterile gloves. 2) Cover and secure topper dressing. 3) Assess wound and surrounding skin. 4) Moisten gauze with prescribed solution. 5) Gently wring out excess solution and unfold. 6) Loosely pack until all wound surfaces are in contact with gauze.

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. -Gauze

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question?

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. -Hydrocolloid

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. -Calcium alginate

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. Which health care team member will the nurse consult?

The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included?

The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. -Transparent

A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention?

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)

A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?