Wound Care Hesi

Which life-threatening Luna straight up with hyperbaric oxygen therapy

Burns, Osteomyelitis, Diabetic ulcers

Which statement by the client recovering from a total hip replacement, indicates an understanding of the discharge instructions

"I will inspect the incision for healing when I change the dressing"

Which appearance would a nurse expect to find when a client has a stage three pressure ulcer

A deep crater with exposed fat

How does cold therapy in the form of an ice pack decrease pain in a musculoskeletal injury

Causing local vasoconstriction and preventing muscle spasm

Which technique would a nurse employee to maintain surgical asepsis

Change the sterile field after sterile water has been spilled on it

Which action would the nurse to when changing the dressing as a client with a large open abdominal wound?

Cleanse the wound with wet, sterile, gauze from the center of the wound outward

Yeah, which factor increases the risk for a room dehiscence in the client who had a major abdominal surgery one day ago

Client being overweight

Which intervention with the nurse take next after emptying a half full Hemovac, portable wound drainage system

Compressing the container before closing the port

After a modified radical mastectomy, a client has two portable wound drainage systems in place which intervention would be initiated for these drainage systems

Compressing the drainage receptacles after emptying them to maintain suction

Which term with the nurse use to describe a clients closed soft tissue injury

Contusion

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. I want a nurse places the client in the row, fowler position with me slightly bent and encourages the client to lie still which messages.

Cover the wound with a sterile towel, moistened with normal saline

Which type of trauma can be caused by the bite of a large dog

Crush injury

Which task with the nurse delegate to an unlicensed nursing personal when caring for a client with pressure injuries

Empty wound drainage containers and report changes in wound appearance

Which intervention with the nurse identify as decreasing the occurrence of pressure injuries for clients who are quadriplegic

Frequent repositioning of client

Which process of wound healing involves placing dead and decomposed issue with fresh collagen tissue

Granulation

Which finding would a nurse expect to find when assessing a diabetic client with like ulcers who has been receiving long-term corticosteroid therapy

Inadequate wound healing

Which client assessment with the nurse determine represents the highest risk for development of pressure ulcers

Incontinence and inability to move independently

Which clinical finding in the lower extremity, is consistent with an arterial ulcers

Lack of hair, thickened toenails, pain at the ulcer site, diminished pedal pulse

Which action would the nurse discuss with the unlicensed assistive personnel to help prevent shearing injuries for clients in a long-term care facility

List the client for position changes rather than sliding

Which action would the nurse implement when completing a sterile wound irrigation and dressing change

Measuring the wound for length, width and depth, if the dressing is dry, moistening with the sterile, normal saline before removal, irrigating the world from the lease contaminated area to the most contaminated, using single stroke, motions to clean the wound, using a new Gosford in stroke, using cotton tipped application for the drains up and clean around the drain losing circulation

Which food with the nurse recommend for a client with multiple abrasions in lacerations to the chest and extremities

Meatloaf

A client is admitted with extensive phone in soft tissue injuries to the lake and sterile dressings were applied two days later when removing the dressings, the nurse finds that one of the dressings has adhere to the tissue in several places which action would the nurse take

Moisten the dressing with sterile saline

Which rationale explains why the nurse empties a Hemovac portable wound suction device abdominal surgery client when it is half full

Negative pressure in the unit lessons as fluid accumulates interfering with further drainage

Which immediate action would the nurse take when noticing bright red drainage on the dressing in in the Jackson-pratt of a client who underwent a below the knee amputation of the left leg?

Place a pressure dressing over the existing dressing on the stump

Which reason explains why the nursing care plan of a paraplegic client includes turning the client every 1 to 2 hours

Prevent pressure injuries

A client with a spinal cord injury tends to assume the low Fowler position excessively. Which area of the body would the nurse identify as the most vulnerable to the development of a pressure ulcer in this client

Sacrum

Which clinical, finding supports the nurses conclusion that a client is experiencing dehiscence 5 days after abdominal surgery

Serosanguinous drainage

Which client with the nurse applying ice pack as a priority intervention

Spider bite client

A nurse is assessing a new client with a pressure injury that presents as a partial thickness alteration that appears as an abrasion and has a red pink wound bed with no tissue sloughing. Which stage of pressure injury with the nurse document

Stage II

Which stage would the nurse use when documenting a pressure ulcer that is full thickness with necrosis from the subcutaneous tissue down to the underlying fascia

Stage III

Which consideration would be used to determine the source of blame for a pressure ulcer that has developed on an emancipated older adult, with dementia, who refused to change positions for extended periods

The client should have been turned regularly

A nurse stops at the scene of an accident and finds a person with a deep laceration on their hand, a fractured arm and leg and abdominal pain. The nurse wraps, a persons hand in a soiled cloth and drives them to the nearest hospital which interpretation would be made about the nurses behavior

The nurse is negligent and can be sued for malpractice

Which statement is true in regard to secondary intention and wound healing

The wound may develop purulent exudate when the tissue dies

Which is the reason wet to dry dressing changes are needed during every shift on a client with a diabetic foot ulcer

To debride the wound and promote healing by second intention

Which factor would the nurse identify as predisposing a client with chronic occlusive arterial disease for the development of ulceration and gangrenous lesions

Trauma from mechanical chemical, or thermal sources

Which nursing action would the nurse take first when discovering a newly admitted client has stage one pressure ulcer

Turn and reposition the client every 2 hours

Which intervention would reduce the possibility of a pressure injury in an immobilized client

Using supports for positioning repositioning the client every 1 to 2 hours while awake using pressure relief cushioning when the client is seated in a chair helping the client learn to shift weight at regular intervals while sitting in a chair using a standardized scale to assess the clients risk for pressure ulcer development

Which statement is true regarding the reconstruction phase of wound healing

Wound dehiscence mostly occurs in the reconstruction face

Which color wound bed would a nurse expect in a wound healing by secondary intention that exhibit some soft acrotic tissue with a semi liquid sloth and exudate

Yellow