Information and Healing (12)
Which action would the nurse perform as part of a wet-to-dry dressing change on a patient's stage 3 sacral pressure injury?
Administer a prescribed PRN oral analgesic 60 minutes before the change.
For which type of wound would the nurse plan to use a wet-to-dry dressing?
An open lesion with purulent drainage and dry brown areas
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient?
Ask about feelings of fatigue or malaise
A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, which instructions are most important for the nurse to teach the patient and family?
Change the patient's position every 1 to 2 hours.
A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8F (38.7C). The patient denies any discomfort. Which action would the nurse take?
Check the patient's temperature again in 4 hours.
A new nurse performs a dressing change on a patient's stage 2 left heel pressure injury. Which action by the new nurse indicates a need for further teaching about pressure injury care?
Cleaning the injury with half-strength peroxide
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?
Document the assessment.
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action would the nurse take?
Elevate the ankle above heart level.
A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing would the nurse apply to the wound?
Hydrocolloid dressing
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy?
Low serum albumin level
A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. Which postoperative intervention would be the nurse's highest priority to promote wound healing?
Maintaining the patient's blood glucose within a normal range
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/L and a band neutrophil count of 11%. Which prescribed action would the nurse take first?
Obtain cultures of the wound.
A patient with a systemic bacterial infection reports feeling cold and has a shaking chill. Which assessment finding will the nurse expect next?
Rising body temperature
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
Separation of proximal wound edges
A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How would the nurse classify this pressure injury?
Stage 3
After the home health nurse teaches a patient's family member about how to care for a sacral pressure injury, which finding indicates that additional teaching is needed?
The family member dries the wound using a hair dryer on a low setting
After receiving a change-of-shift report, which patient would the nurse assess first?
The patient receiving chemotherapy who has a temperature of 102F
When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing?
The patient takes oral hypoglycemic agents daily.
Which patient's care could the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?
The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury
The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic?
Undermining
