Exam 46: Skin Integrity and Wound Care

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

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?

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

The nurse is caring for a patient who has a stage 4 pressure injury and is awaiting plastic surgery consultation.Which of the following specialty beds would be most appropriate?

The nurse is caring for a patient with a stage 3 pressure injury.The nurse has assigned a nursing diagnosis of Risk for infection.Which intervention would be most important for this patient?

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? (Select all that apply. )

The nurse is admitting an older patient from a nursing home.During the assessment,the nurse notes a shallow open pressure injury without slough on the right heel of the patient.How would this pressure injury be staged?

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure injuries.The nurse has become competent in the care of pressure wounds and recognizes that which of the following is a staged pressure injury that does not require a dressing?

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.What is the major element involved in the development of a pressure injury?

On inspection of the patient's wound,the nurse notes that it has a large amount of exudate.Which of the following is an appropriate dressing for the nurse to select?

The patient in medical-surgical acute care has received a nursing diagnosis of Impaired skin integrity.Which health care provider does the nurse consult?

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a score of 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 patient after an open repair of an abdominal aortic aneurysm.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 using the Braden scale to complete a skin risk assessment.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 total Braden scale score?

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,what is the next best step?

The nurse is caring for a patient with a stage 4 pressure injury.The nurse assigns which of the following nursing diagnoses?

The nurse is caring for a patient with a stage 2 pressure injury 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? (Select all that apply. )

The nurse is caring for a patient who has undergone 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 in the burn unit.The nurse recalls that this type of wound heals by which process?