Exam 93: Skin Integrity and Wound Care

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

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

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 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 staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers.The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage

The wound care nurse visits a patient in the long-term care unit.The nurse is monitoring a patient with a stage III pressure ulcer.The wound seems to be healing,and healthy tissue is observed.How would the nurse stage this ulcer?

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

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 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

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 caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing.Which of these actions should the nurse take first?

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

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

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

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.The nurse is able to identify that the major element involved in the development of a decubitus ulcer is