Exam 48: Skin Integrity and Wound Care

The nurse is caring for a patient who is immobile and is at risk for skin impairment.The plan of care includes turning the patient.What is the best method for repositioning the patient?

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers.The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include

The nurse is caring for a patient with potential skin breakdown.Which components would the nurse include in the skin assessment?

The nurse is completing a skin risk assessment utilizing the Braden scale.The patient has some sensory impairment and 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.What would be the patient's Braden scale total score?

The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation.Which of the following specialty beds would be most appropriate?

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

The nurse is caring for a patient who has experienced a laparoscopic appendectomy.The nurse recalls that this type of wound heals by

The nurse is caring for a patient after an open abdominal aortic aneurysm repair.The nurse requests an abdominal binder and carefully applies the binder.What is the best explanation for the nurse to use when teaching the patient the reason for the binder?

The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection.The patient is unconscious and bedridden.The nurse is completing the plan of care and is writing goals for the patient.What is the best goal for this patient?

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.What would be the nurse's next best step?