M21.3TB

A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate. Three days after the​ debridement, the​ client's surgical wound was closed with staples that are aiding in healing. Given this​ information, which of the following terms should the nurse use when documenting this​ client's care? A. Tertiary intention healing B. Primary intention healing C. Quaternary intention healing D. Secondary intention healing

A

An older adult client diagnosed with chronic obstructive pulmonary disease​ (COPD) is scheduled for a total knee replacement. What should the nurse include in this​ client's plan of care to address the risk of an alteration in tissue​ integrity? A. Assess postoperative wound healing. B. Expect purulent drainage. C. Restrict protein intake. D. Monitor urine output.

A

The nurse is planning care for a client with a surgical wound. Which goal related to the surgical wound is most appropriate for this​ client? A. The client will increase ambulation. B. The client will regain intact skin. C. The client will resume independent activities of daily living​ (ADLs). D. The client will discharge to home as soon as possible.

B

A client recovering from abdominal surgery tells the nurse that​ "something popped" in his abdominal incision. Upon​ inspection, the nurse finds that evisceration has occurred. What actions by the nurse are​ appropriate? Select all that apply. A. Turn the client onto his abdomen. B. Position the client in bed with his knees bent. C. Pack the​ client's wound with nonadherent gauze. D. Notify the​ client's surgeon. E. Cover the incision with a​ large, saline-soaked dressing.

B, D, E

A nurse working in the intensive care unit​ (ICU) is caring for a client who is 10 days postoperative after open abdominal surgery. The client has a​ well-approximated midline surgical incision that has numerous​ staples, and the nurse notes a​ "healing ridge" is present. Based on this​ information, the incision is currently in which phase of the healing​ process? A. Inflammatory phase B. Synthesis phase C. Proliferative phase D. Maturation phase

C

An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which intervention best addresses the​ client's nutritional​ needs? A. Encourage ambulation. B. Medicate for pain prior to dressing changes. C. Request a dietary consult. D. Assist with​ deep-breathing exercises.

C

Hemostasis and phagocytosis are characteristic of which stage of the wound healing​ process? A. Proliferative phase B. Maturation phase C. Inflammatory phase D. Granulation phase

C

The nurse is assessing a client with a surgical wound. Which finding indicates that care has been effective for this​ client? A. The​ client's temperature is 100degreesF. B. There is only a scant amount of purulent drainage on the dressing. C. The client performs wound care independently. D. A small area of erythema and edema is present.

C

Which of the following findings suggests that a wound is infected with pyogenic​ bacteria? A. Sanguineous exudate B. Serosanguineous exudate C. Purulent exudate D. Serous exudate

C

Which statement about wound care across the lifespan is​ correct? A. ​"Pressure injuries and contact irritation are rare among newborns and infants in​ NICUs." B. ​"When applying transparent dressings on older adult​ clients, do not hold the skin​ taut, because doing so can cause​ damage." C. ​"In young​ children, staph bacteria and fungi are the most common causes of infection in minor​ wounds." D. ​"As compared to younger​ clients, older adults have a heightened inflammatory​ response, which can contribute to delayed wound​ healing."

C

A client has a laceration that was closed with tissue adhesive. By what process will this wound​ heal? A. Tertiary intention B. Secondary intention C. Delayed primary intention D. Primary intention

D

A client has a wound on the left lateral aspect of the thigh. Which action by the nurse would best promote wound healing for this​ client? A. Restricting fluids B. Positioning the client with weight directly on the wound C. Enforcing strict bedrest D. Positioning the client to keep weight off the wound

D

A client is admitted to the hospital with a gunshot wound to the leg. Which nursing diagnosis is a​ priority? A. Anxiety B. Ineffective Coping C. Situational Low​ Self-Esteem D. Risk for Infection

D

Which of the following medications may be discontinued in a client who is experiencing delayed wound​ healing? A. Topical growth factors B. Oral antibiotics C. Topical antibiotics D. Oral prednisone

D