1245 - Wounds (the point)
A client says, "I hate the idea of being an invalid after they cut off my leg." Which response by the nurse would be the most therapeutic?
"Tell me more about how you're feeling."
The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?
Apply a hydrocolloidal dressing.
Which is the best nursing response to make when a client asks why there are small lumps under the suture line of the incision three weeks after abdominal surgery?
"Those lumps are caused by new tissue growing at different rates."
A nurse is providing wound care to a client 1 day after an appendectomy. A drain was inserted into the incisional site during surgery. What should the nurse do to provide wound care?
Clean the area around the drain, moving away from the drain.
The nurse assesses a client with a fever and a draining arm wound. The healthcare provider suspects a methicillin-resistant Staphylococcus aureus (MRSA) infection and issues orders. What health care provider order will the nurse implement first?
Cleanse the area around the wound, and obtain a culture.
The nurse is performing wound care on a client with an open fracture. What is the nurse's priorityaction to clean the wound?
Irrigate the wound with normal saline.
The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care?
Place the client on a pressure redistribution bed.
The nurse is bathing a client and discovers a pressure ulcer on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first?
Position the client off of the ulcer.
While caring for a client who's immobile, a nurse documents this information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
Risk for impaired skin integrity related to immobility
When caring for a patient with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?
Using normal saline solution to clean the ulcer and applying a protective dressing as necessary
When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers?
a client who has a decreased serum albumin level
When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing?
adequate circulatory status
A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?
lean meats and low-fat milk
The nurse is caring for an immobile client. Which intervention should the nurse prioritize?
keeping the skin clean and dry with gentle soap
Which nutritional deficiency may delay wound healing?
lack of vitamin C
When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by:
proper positioning and moving of the client.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 × 1-inch (3 × 3-cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record?
stage II pressure ulcer
Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?
The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.
A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?
The dressing should keep the wound moist.
