Exam 93: Skin Integrity and Wound Care

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

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 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 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 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 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?

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 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 IV pressure ulcer.The nurse assigns which of the following nursing diagnoses?

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

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

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 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 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 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 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 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 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