Prep U chp 31

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?" Explanation: The client's health history is an essential component for assessing the client's integumentary status and identification of risk factors for problems with the skin

The nurse is discussing care of a client's wound that has nonviable tissue in the base with the wound care nurse. The wound care nurse recommends that the nurse utilizes a dressing that would promote autolytic debridement of the wound. Which of the following dressings should the nurse select?

Hydrocolloid

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

Stage III

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure ulcer?

Use pillows to maintain a side-lying position as needed.

secondary intention

are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue

tertiary intention or delayed primary intention

are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed

The nurse caring for client that had abdominal surgery 12 hours ago notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

document the findings

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing?

fish

primary intention

form a clean, straight line with little loss of tissue

dehiscence

is wound separation, parital or total not wound healing

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

mechanical debridement

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

stage II

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. a) a client who is obese b) an older adult who is confined to bed c) a 10-year-old client with a surgical incision d) a client who is taking corticosteroid drugs e) a client who eats a diet high in vitamins A and C f) a client with a peripheral vascular disorder

• an older adult who is confined to bed • a client with a peripheral vascular disorder • a client who is obese • a client who is taking corticosteroid drugs

A nurse is caring for a client who has recently undergone hernial surgery. What are possible causes of complications with regard to surgical wounds? Select all that apply

• insufficient protein and vitamin C intake • weak tissue and muscular support due to obesity • distension of the abdomen from accumulated intestinal gas