Exam 93: Skin Integrity and Wound Care

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

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 patient has been provided a nursing diagnosis of Risk for skin impairment and has a 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 cleansing a wound site.As the nurse administers the procedure,what intervention should be included?

The nurse is caring for a medical-surgical patient.To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility,which intervention is most important for the nurse to complete?

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?

A patient has developed a decubitus ulcer.What laboratory data would be important to gather?

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 with a large abrasion from a motorcycle accident.The nurse recalls that if the wound is kept moist,it can resurface in _____ day(s).

The nurse is caring for a patient with a stage II pressure ulcer 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?