Exam 37: Skin Integrity and Wound Care

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

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? (Select all that apply.)

The primary health care provider has ordered the patient to wear an elastic bandage to the left ankle owing to a severe strain.The nurse has instructed the patient on proper application of the elastic bandage.Which statement indicates the patient needs more teaching?

A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan.The admitting diagnosis is failure-to-thrive.On admission,the patient was found to have a wound on the right scapula.The nurse noted full-thickness tissue loss with tunneling,but did not note any bone,tendon,or muscle.This was correctly identified as what stage of a pressure ulcer?

The nurse is preparing to change a large wound dressing on the patient's buttock.Which intervention should the nurse address first?