Exam 48: Skin Integrity and Wound Care

The nurse is caring for a medical-surgical patient.To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility,which intervention is most important for the nurse to complete?

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

The nurse is caring for a patient who is experiencing a full-thickness repair.The nurse would expect to see which of the following in this type of repair?

A patient has developed a decubitus ulcer.What laboratory data would be important to gather?

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago.The patient sustained a head injury and is unconscious.The nurse is able to identify that the major element involved in the development of a decubitus ulcer is

The nurse is caring for a patient with a pressure ulcer on the left hip.The ulcer is black.The nurse recognizes that the next step in caring for this patient includes

The nurse is caring for a patient with a wound.The patient appears anxious as the nurse is preparing to change the dressing.What should the nurse do to decrease the patient's anxiety?

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission.The nurse has implemented interventions for this nursing diagnosis.Upon reassessment,which Braden score would be the best sign that the risk for skin breakdown is decreasing?

The nurse is caring for a postoperative medial meniscus repair of the right knee.To assist with pain management following the procedure,which intervention should the nurse implement?

The nurse is caring for a patient with a stage IV pressure ulcer.The nurse assigns which of the following nursing diagnoses?

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems.The patient is at risk for skin impairment.Which initial interventions should the nurse select to decrease this risk?

Which of the following would be the most important piece of assessment data to gather with regard to wound healing?

A patient presents to the emergency department with a laceration of the right forearm caused by a fall.After determining that the patient is stable,the next best step is to

The wound care nurse visits a patient in the long-term care unit.The nurse is monitoring a patient with a stage III pressure ulcer.The wound seems to be healing,and healthy tissue is observed.How would the nurse stage this ulcer?

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers.The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage

The nurse is completing an assessment on an individual who has a stage IV pressure ulcer.The wound is odorous,and a drain is currently in place.The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following?

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity.The nurse consults a

The nurse has collected the following assessment data: right heel with reddened area that does not blanch.What nursing diagnosis would the nurse assign?

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing.Which of these actions should the nurse take first?