Fundamentals: Josephine Morrow

The nurse is completing an admission assessment on a patient admitted for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition? (Select all the apply.)

Poor hygiene Diabetes mellitus Poor circulation Obesity

The nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the plan of care for this patient? (Select all that apply.)

Provide meticulous skin care. Perform neurovascular checks to look for changes. Monitor patient for signs of skin breakdown. Assist with range of motion exercises to lower extremities.

The nurse is providing education to Ms. Morrow and her daughter on nutrition. What is the best dietary choice to promote wound healing?

Baked chicken

The nurse assess a wound and documents it as stage IIi. What did the nurse observe when the would was assessed.

Full-thickness tissue loss, possibly with visible subcutaneous fat.

The nurse is providing education to Ms. Morrow and her daughter on management of venous stasis in the lower extremities. What would be appropriate for the nurse to include in the teaching sessions?

Put an anti embolism stockings as soon as you get up in the morning and wear them all day.

The nurse is irrigating a patient's wound when the patient complains of pain. What is the appropriate action by the nurse?

Stop the procedure and administer the ordered analgesic.

The nurse has received an order to apply a hydrocolloid dressing to Ms. Morrow's right lower extremity. Which statement, if made by the nurse, would indicate the need for further education?

The dressing will need to be held in place by surgical tape.

Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's wound. What is the appropriate response by the nurse?

The procedure helps remove drainage and debris from the wound.

The nurse is preparing to irrigate a patient's wound. Upon assessment, the wound appears be healing and the wound bed is beefy red. What solution should the nurse select for this procedure?

Normal saline

The nurse is performing an assessment of Ms. Morrow's wound. What should be included in the documentation? (Select all that apply.)

Odor Drainage Tunneling Location