Question 1

Which statement by the patient indicates that additional teaching is needed about the application of an elastic bandage to the ankle?

Accepted Answer

A)  "I will take the bandage off if my toes start to tingle." 
B)  "I need to make sure the bandage is applied smoothly." 
C)  "I need to watch my toes for swelling and feeling cold." 
D)  "I will to wrap the bandage from my shin toward my toes." 
A)  "I will take the bandage off if my toes start to tingle." 
B)  "I need to make sure the bandage is applied smoothly." 
C)  "I need to watch my toes for swelling and feeling cold." 
D)  "I will to wrap the bandage from my shin toward my toes."

Question 2

On admission a patient is noted to have an alteration in skin integrity on the right heel.The nurse uses the Braden Scale.Which areas will the nurse assess when using this scale?

Accepted Answer

A)  Mobility 
B)  Nutrition 
C)  Infection 
D)  Activity 
E)  Friction 
A)  Mobility 
B)  Nutrition 
C)  Infection 
D)  Activity 
E)  Friction

Question 3

What is the primary advantage of a hydrogel dressing for wound healing?

Accepted Answer

A)  Provide moisture needed for wound healing. 
B)  Act as an absorbent to collect wound drainage. 
C)  Provide negative pressure to promote healing. 
D)  Provide protection from the external environment. 
A)  Provide moisture needed for wound healing. 
B)  Act as an absorbent to collect wound drainage. 
C)  Provide negative pressure to promote healing. 
D)  Provide protection from the external environment.

Question 4

A postoperative abdominal surgery patient has been admitted to the surgical floor.The nurse is aware that wound healing is delayed due to complications.Which conditions would prevent normal wound healing at the surgical site?

Accepted Answer

A)  Dehiscence 
B)  Evisceration 
C)  Debridement 
D)  Hemostasis 
E)  Hemorrhage 
A)  Dehiscence 
B)  Evisceration 
C)  Debridement 
D)  Hemostasis 
E)  Hemorrhage

Question 5

Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired skin integrity related to immobility and muscle weakness?

Accepted Answer

A)  The patient's skin will remain intact without redness or ulceration. 
B)  The nurse will assess the patient's skin daily for any sign of breakdown. 
C)  The patient will verbalize at least two methods to prevent skin breakdown. 
D)  The patient's wounds will be kept clean and will not develop signs of infection. 
E)  The nurse will reposition the patient every 2 hours and pad bony prominences. 
A)  The patient's skin will remain intact without redness or ulceration. 
B)  The nurse will assess the patient's skin daily for any sign of breakdown. 
C)  The patient will verbalize at least two methods to prevent skin breakdown. 
D)  The patient's wounds will be kept clean and will not develop signs of infection. 
E)  The nurse will reposition the patient every 2 hours and pad bony prominences.

Exam 38: Skin Integrity and Wound Care

Which statement by the patient indicates that additional teaching is needed about the application of an elastic bandage to the ankle?

On admission a patient is noted to have an alteration in skin integrity on the right heel.The nurse uses the Braden Scale.Which areas will the nurse assess when using this scale?

What is the primary advantage of a hydrogel dressing for wound healing?

A postoperative abdominal surgery patient has been admitted to the surgical floor.The nurse is aware that wound healing is delayed due to complications.Which conditions would prevent normal wound healing at the surgical site?

Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired skin integrity related to immobility and muscle weakness?

Professional Nursing

Health and Wellness

The Health Care Delivery System

Community-Based Nursing Practice

Legal Principles in Nursing

Ethics

Evidence-Based Practice

Critical Thinking

Nursing Process

Informatics and Documentation

Communication

Patient Education

Managing Patient Care

Infection Prevention and Control

Vital Signs

Health Assessment and Physical Examination

Administering Medications

Fluid, Electrolyte, and Acid-Base Balances

Complementary and Alternative Therapies

Caring in Nursing Practice

Cultural Awareness

Spiritual Health

Growth and Development

Self-Concept and Sexuality

Family Dynamics

Stress and Coping

Loss and Grief

Exercise and Activity

Immobility

Safety

Hygiene

Oxygenation

Sleep

Pain Management

Nutrition

Urinary Elimination

Bowel Elimination

Sensory Alterations

Surgical Patient

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