Exam 35: Skin Integrity-Wound Healing

While applying a wet-to-dry dressing,how would the nurse explain to the patient how this procedure works for promoting healing? A wet-to-dry dressing is a:

The nurse admits an older adult patient to the long-term care facility.When assessing for pressure ulcer risk,what should the nurse do after conducting the first Braden scale assessment?

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago,and now the ulcer appears to be a shallow crater involving only partial skin loss.What would the nurse now classify the pressure ulcer as?

Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives:

What intervention would be most appropriate for a wound with a beefy red wound bed?

A man was involved in a motor vehicle accident yesterday.He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator.Which of the following would be an appropriate nursing diagnosis for him at this time?

What are two risk assessment tools used in the United States to evaluate a patient's risk for pressure ulcers? Select all that apply.

What is a common characteristic of aging skin?

A patient had abdominal surgery.The incision has been closed by primary intention,and the staples are intact.To provide more support to the incision site and decrease the risk of dehiscence,it would be appropriate to apply which of the following?

The nurse would question a prescription for application of cold therapy to which patient? The patient with a:

The home health nurse learns that an elderly patient isn't able to get to the grocery store.She doesn't have much food in her home,and eats and drinks little.Most of her time is spent sitting in her chair watching television,often not realizing that she has bladder leakage.Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply.

While assessing a new wound,the nurse notes red,watery drainage.How should the nurse describe this type of drainage when documenting?

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy.She has a pressure area on her coccyx measuring 5 cm by 3 cm.The area is covered with 100% eschar.What would the nurse identify this as?

The nurse would know care for a stage II pressure ulcer is achieving the desired goal when:

The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit.Which one is it most likely to be?

A patient has an area of nonblanchable erythema on his coccyx.The nurse has determined this to be a stage I pressure ulcer.What would be the most important treatment for this patient?

Which client does the nurse recognize as being at greatest risk for pressure ulcers?

What is the function of the stratum corneum?

Of the following,which is the best choice for performing wound irrigation?

A patient had a CVA (stroke)2 days ago,resulting in decreased mobility to her left side.During the assessment,the nurse discovers a stage I pressure area on the patient's left heel.What is the initial treatment for this pressure ulcer?