Exam 37: Skin Integrity and Wound Care

A patient is being seen in the Emergency Department for a puncture wound on the foot.The patient was walking in a construction site,but is unsure what caused the injury.During the initial assessment the nurse determines if the patient has received a tetanus toxoid injection within which time frame?

Which patient is best suited for heat therapy?

A pre-teen quadriplegic patient was admitted with pressure ulcers to both ankles.The nurse should assess which parameters for a wound assessment? (Select all that apply.)

A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus.The admitting nurse notes that an area of redness on the right malleolus is nonblanchable.The nurse correctly identifies this pressure ulcer at what stage?

A patient is wearing an abdominal binder after abdominal surgery.What does the nurse need to assess and document about the patient?

When a patient has full-thickness loss but the depth is unknown,how should the nurse classify this pressure ulcer?

A surgical wound requires a hydrogel dressing.What is the primary advantage of a hydrogel dressing?

An elderly patient who resides in a nursing home is suffering from a respiratory infection.During the illness,the patient has become incontinent of both urine and stool.The nursing staff used a special cleanser on the perineum,put a moisture barrier on the exposed area,and used absorbent briefs to prevent the skin from becoming soft because of the moisture.What was the staff trying to prevent?

A patient's full-thickness wound is establishing a clean wound bed and obtaining bacterial balance.This patient is in which phase of wound healing?

An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework.During a bath,the assistive nursing personnel noticed that there was a large blister on the patient's right heel.The patient denies knowledge of having injured self.It was reported to the nurse who correctly documented it as what stage of a pressure ulcer?

An elderly patient has been admitted to the hospital for pneumonia.Which factor could put this patient at risk for a pressure ulcer?

A patient's draining wound is pale and watery with a combination of plasma and red cells.How should the nurse document this finding?

The student nurse asks a nursing assistive personnel (NAP)to help move a patient up in bed.The student nurse instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation?

An elderly patient is admitted to the hospital for a bowel obstruction.The patient is immobile and the nurse notices that there is a reddened area on the right heel.When the nurse presses on the area it does not turn lighter in color.How should the nurse document the tissue condition?

Assistive personnel ask the nurse the differences between wound healing by primary and secondary intention.The nurse's best response is that healing by primary intention occurs when the skin edges:

A postoperative patient visits the ambulatory care clinic complaining of just "not feeling well." The patient has an elevated temperature.Which assessment finding should indicate to the nurse that the wound has become infected?

A patient is admitted to the hospital with a pressure ulcer on the sacrum.The wound is open with exposed bone.The nurse should document this pressure ulcer at what stage?

A patient who has undergone a colectomy is demonstrating wound healing.The nurse correctly identifies the wound phase characterized by synthesis of collagen fibers as which of the following?

Which therapy should the nurse choose that will improve a patient's circulation,relieve edema,and promote concentration of pus and drainage?

The nurse is caring for a patient with a necrotic hip wound.Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?