Exam 48: Skin Integrity and Wound Care

The nurse is caring for a patient who is at risk for skin impairment.The patient is able to sit up in a chair.The nurse includes this intervention in the plan of care.How long should the nurse schedule the patient to sit in the chair?

The nurse is caring for a patient with wound healing by tertiary intention.Which factors does the nurse recognize as influencing wound healing?

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer.After the collaboration,the nurse orders a meal plan that includes increased

The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder.The nurse's responsibilities and activities before applying the bandage and binder include which of the following?

The nurse is completing a skin assessment on a medical-surgical patient.Which nursing assessment questions should be included in a skin integrity assessment?

The nurse is admitting an older patient from a nursing home.During the assessment,the nurse notes a shallow open ulcer without slough on the right heel of the patient.This pressure ulcer would be staged as stage

The nurse is caring for a patient in the burn unit.The nurse recalls that this type of wound heals by

The home health nurse is caring for a patient with impaired skin integrity in the home.The nurse is reviewing dressing changes with the caregiver.Which intervention assists in managing the expenses associated with long-term wound care?

The nurse is completing an assessment of the skin's integrity,which includes

The nurse is caring for a patient with a large abrasion from a motorcycle accident.The nurse recalls that if the wound is kept moist,it can resurface in _____ day(s).

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 stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach.The nurse evaluates the need for several consults.Which of the following should always be included in the consults?

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?

The nurse is caring for a patient with a healing stage III pressure ulcer.The wound is clean and granulating.Which of the following orders would the nurse question?

The nurse is caring for a patient with a stage III pressure ulcer.The nurse has assigned a nursing diagnosis of Risk for infection.Which intervention would be most important for this patient?

The nurse is completing a skin assessment on a patient with darkly pigmented skin.Which of the following would be used first to assist in staging an ulcer on this patient?

The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity.Which of the following outcomes when met indicate progression toward goals?

The nurse is caring for a patient with a stage IV pressure ulcer.The nurse recalls that a pressure ulcer takes time to heal and is an example of

Which nursing observation would indicate that a wound healed by secondary intention?

The nurse is caring for a postpartum patient.The patient has an episiotomy after experiencing birth.The physician has ordered heat to treat this condition,and the nurse is providing this treatment.This patient is at risk for