Skin Integrity and Wound Healing

A nurse notices a wound that has developed on the lower back of a client that has adipose tissue exposed with full-thickness skin loss. What stage is this pressure injury? 1 3 2 4

3

Which client is at highest risk for wound dehiscence? A 20 year old thin female who underwent an emergency appendectomy A 55 year old obese female who underwent an abdominal hysterectomy A 75 year old thin female who underwent a total hip replacement s/p fall A 40 year old obese male who underwent back surgery for a herniated disk

A 55 year old obese female who underwent an abdominal hysterectomy

Pressure ulcers are directly caused by which of the following conditions at the site? Shearing forces Inadequate venous return Edema Compromised blood flow

Compromised Blood Flow

What intervention would be most appropriate for a wound with a beefy red wound bed? Autolytic débridement Wet-to-dry dressings changed 3 times a day Dressing to keep the wound moist and clean Mechanical débridement

Dressing to keep the wound moist and clean

What is the primary difference between acute and chronic wounds? Chronic wounds: Exceed the typical healing time, but acute wounds heal readily. Result from pressure, but acute wounds result from surgery. Are usually infected, whereas acute wounds are contaminated. Are full-thickness wounds, but acute wounds are superficial.

Exceed the typical healing time, but acute wounds heal readily

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? Enzymatic débridement Sheet hydrogel Frequent turn schedule Transparent film dressing

Frequent turn schedule

While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as? Serosanguineous Sanguineous Purosanguineous Serous

Serosanguineous

What is the primary goal that the nurse should establish for a patient with an open wound? The wound will remain free of infection throughout the healing process. Client increases caloric intake throughout the healing process. Client completes antibiotic treatment as ordered. The wound will remain free of scar tissue at healing.

The wound will remain free of infection throughout the healing process

Which of the following describes the difference between dehiscence and evisceration? Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

What is one skin integrity issue that should be addressed with an older adult client that has been admitted? Adult acne Decreased fat deposit Overactive sweat glands Xerosis

Xerosis