Exam 46: Skin Integrity and Wound Care

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 nurse is collaborating with the dietitian in treatment of a patient with a stage 3 pressure injury.After the collaboration,the nurse orders a meal plan that includes increased levels of what?

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

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

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

The nurse is caring for a patient with a pressure injury on the left hip.The pressure injury is black.The nurse recognizes that the next step in caring for this patient includes which of the following?

The nurse is caring for a patient with wound healing by tertiary intention.Which factors does the nurse recognize as influencing wound healing? (Select all that apply. )

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 a pressure injury on this patient?

The nurse is completing an assessment on an individual who has a stage 4 pressure injury.The wound is malodorous,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 nurse is caring for a patient who is undergoing a full-thickness repair.The nurse would expect to see which of the following in this type of repair?

The nurse is caring for a patient with a healing stage 3 pressure injury.Upon entering the room,the nurse notices an odour 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 2 pressure injury 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 with a stage 4 pressure injury.The nurse recalls that a pressure injury takes time to heal and that the healing process is an example of which of the following?

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

The nurse is caring for a patient with a healing stage 3 pressure injury.The wound is clean and granulating.Which of the following orders would the nurse question?

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

The nurse determines that the patient's wound may be infected.In order to obtain a quantitative swab for wound culture,which of the following actions should the nurse take?

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure injuries.The nurse recognizes that the risk factors that predispose a patient to pressure injury development include which of the following?

A patient has developed a pressure injury.What laboratory data would be important to gather?