Chapter 48 Questions

23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? Standard mattress Nonpowered redistribution air mattress Low-air-loss therapy unit Lateral rotation

Nonpowered redistribution air mattress

Which statement indicates the nurse has a correct understanding of a patient's pressure-reducing bed? "The support surface may be foam or gel." "I will have to turn the patient less frequently." "This type of mattress is avoided for obese patients." "It is a type of treatment that focuses on vasodilation."

"The support surface may be foam or gel."

Which parameters would the nurse include when charting about a patient's warm compress on the left leg? Select all that apply .a. Type of therapy b. Length of therapy c. Type of drainage d. Type of cleaning solution used e. Length of compress

.a. Type of therapy b. Length of therapy c. Type of drainage

Arrange the steps of pressure injury care in the appropriate order: Perform hand hygiene and apply clean gloves Expose the pressure injury and surrounding skin. Keep the remaining parts covered. Remove gloves, perform hand hygiene, and apply sterile gloves Apply topical agents as prescribed Clean the pressure injury thoroughly with normal saline or a cleaning agent

1. Perform hand hygiene and apply clean gloves 2. Expose the pressure injury and surrounding skin. Keep the remaining parts covered. 3. Clean the pressure injury thoroughly with normal saline or a cleaning agent 4. Remove gloves, perform hand hygiene, and apply sterile gloves 5. Apply topical agents as prescribed

Which patient situations are of immediate concern A patient experiencing shock A patient profusely bleeding from a wound The patient has an infected wound A patient has an eviscerated wound a patient has a stage for pressure injury

A patient experiencing shock A patient profusely bleeding from a wound A patient has an eviscerated wound a patient has a stage for pressure injury

Which factor would not place a patient at risk of burns during heat therapy young age Areas of edema Abscessed tooth Peripheral vascular disease

Abscessed tooth

1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include A diet low in calories and fat. Alteration in level of consciousness. Shortness of breath. Muscular pain.

Alteration in level of consciousness.

Which factors can place a patient at risk for a pale dry wound SATA Anemia diabetes wound infection vascular disease nutritional deficiencies

Anemia diabetes vascular disease nutritional deficiencies

Which statement is true regarding cold application Cold application causes vasodilation It reduces blood viscosity Cold application decreases muscle tension It increases tissue metabolism

Cold application decreases muscle tension

14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? Complaint by patient that something has given way Protrusion of visceral organs through a wound opening Chronic drainage of fluid through the incision site Drainage that is odorous and purulent

Complaint by the patient that something has given way

24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes Monitoring of the wound. Irrigation of the wound. Debridement of the wound. Management of drainage.

Debridement of the wound.

Which intervention would not be necessary for a patient who has impaired skin integrity Demonstrate correct repositioning techniques Apply dressings to support moist wound healing Performing ongoing ruined and risk assessment Apply a moisture barrier to the area at least three times daily

Demonstrate correct repositioning techniques

What is an advantage of warm, moist application in wound healing?

Does not promote sweating

A 76-year-old female patient who has osteoarthritis in mild hypertension develops redness and oozing a foul smelling tan colored drainage from her hip incision on post operative day for. Because of the pain at the incision site she needs assistance and turning and transferring her self from a bed to the which intervention would the nurse avoid? Elevating the head of the bed to 45° Irrigating the wound with saline solution twice a day Helping the patient with repositioning every 90 minutes Checking the patient's pain level and offering analgesics at frequent intervals

Elevating the head of the bed to 45°

Which cues with the nurse observe for a patient with an infected lateral malleolus wound SATA Erythema noted on the superior portion of the wound Purulent, malodorous drainage 1.5 cm wound with serous drainage and tissue epithelializatiin Temperature of 102°F Pain level of 2/10

Erythema noted on the superior portion of the wound Purulent, malodorous drainage Temperature of 102°F

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat?Ingest 25% of each meal during hospitalization.Report that pain management regimen lowers pain level to 6/10 or lower within the shift. Show acceptance of the change in body image by continuing to have the nurse change the dressing after 1 week. Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week

Match the pressure injury stage to its characteristics.Stage 1, Stage 2, Stage 3, or Unstageable Extends into the subcutaneous tissue but not the fascia Intact, nonblistered skin Full-thickness wound with eschar Involves the epidermis and dermis

Extends into the subcutaneous tissue but not the fascia - stage 3 Intact, nonblistered skin - stage 1 Full-thickness wound with eschar - Unstageable Involves the epidermis and dermis - stage 2

Which piece of knowledge is not required for assessing a patient's risk of developing pressure injuries Pathogenesis of pressure injuries Factors contributing to pressure injury formation Factors contributing to wound healing Factors contributing to inflammation and infection

Factors contributing to inflammation and infection

7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of Primary intention. Partial-thickness wound repair. Full-thickness wound repair. Tertiary intention.

Full-thickness wound repair.

Which body fluid poses a high risk of skin breakdown? Select all that apply Gastric drainage Pancreatic drainage Saliva Bile Urine

Gastric drainage Pancreatic drainage

36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? Gentle cleaners and thorough drying of the skin Absorbent pads and garments Positioning with use of pillows Therapeutic beds and mattresses

Gentle cleaners and thorough drying of the skin

9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? Eschar Slough Granulation Purulent drainage

Granulation

6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? Cotton-tipped applicator Disposable measuring tape Sterile gloves Halogen light

Halogen light

Which patient scenario would prompt the nurse to question a prescription for cold therapy? Has a strong pulse Has edema present Has an absence of cyanosis Has 16 respirations per minute

Has edema present

19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? I think I will be ready to go home early next week. I am so weak and tired, I want to feel better. I am ready for my bath and linen change as soon as possible. I am hoping there will be something good for dinner tonight.

I am ready for my bath and linen change as soon as possible.

39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage I. II. III. IV.

I.

5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage I. II. III. IV.

II.

Which student nurse statement about assessing dark skinned patients indicate adequate learning select all that apply Cyanosis is easily detected in dark skinned patients Identification of early pressure ulcers may be difficult The elbow is a good sight for underlying skin color identification Hyperpigmentation on the sacra indicates the patient has cyanosis Assessment of skin temperature and edema should be considered a priority Assessment of change in tissue consistency in relation to surrounding areas should be a priority

Identification of early pressure ulcers may be difficult Assessment of skin temperature and edema should be considered a priority Assessment of change in tissue consistency in relation to surrounding areas should be a priority

30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? Ineffective tissue perfusion Risk for infection Imbalanced nutrition: less than body requirements Acute pain

Ineffective tissue perfusion

20. A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to Inspect the wound for bleeding. Inspect the wound for foreign bodies. Determine the size of the wound. Determine the need for a tetanus antitoxin injection.

Inspect the wound for bleeding.

How is the nursing care for a patient who has a stage for pressure injury different from that for a patient who has a stage one pressure injury Stage four requires keeping the patient out of a slouched position Stage four requires the use of low air loss alternating pressure or air fluidized support surface Stage four requires keeping the patient out of a prolonged head of bed elevation position Stage four requires consulting a seating specialist for the appropriate seating surface for the patient

Stage four requires the use of low air loss alternating pressure or air fluidized support surface

The nursing instructor is discussing the Braden scale for pressure injury development risk with a nursing student. Which of the students statements is incorrect? The Braden skill is shown sufficient predictive validity and accuracy for all patients The tool was developed based on risk factors in a nursing home population The scale contains six sub scales and the total square ranges from 6 to 23 It is the most widely used risk assessment tool for pressure injuries

The Braden skill is shown sufficient predictive validity and accuracy for all patients

42. The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder? The binder creates pressure over the abdomen. The binder supports the abdomen. The binder reduces edema at the surgical site. The binder secures the dressing in place.

The binder supports the abdomen.

13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? The incision site has started to itch. The incision site is approximated. The patient has pain at the incision site. The incision has a mass, bluish in color.

The incision has a mass, bluish in color. --> hematoma

When obtaining a wound culture to determine the presence of infection from where should the specimen be taken Necrotic tissue Wound drainage Drainage on the dressing The wound after it has been cleaned with normal saline

The wound after it has been cleaned with normal saline

Which reasoning explains why a nurse measures wound size during an initial wound assessment? To determine the proper medication amount for the wound To help assess progression of wound healing To provide evidence for the presence of infection To reassure patients they are receiving proper care

To help assess progression of wound healing

Which Factor might cause an acute wound select all that apply Trauma pressure surgical incision vascular compromise repetitive insults to tissue

Trauma surgical incision

Which equipment would the nurse consider when developing a nursing plan for an immobile patient whose skin is intact but is that a high risk of impaired skin integrity SATA Consider either low air loss alternating pressure or air fluidized support surface Use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown Consider the use of a wheelchair cushion Using active support surface such as an overlay or mattress when frequent manual repositioning is difficult Avoid prolonged out of bed elevation and a slouch position that places pressure and sheer on the sacred in coccyx

Use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown

8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). a. 4 b. 2 c. 1 d. 7

a. 4

Which nursing action is appropriate when providing cae to a patient who is diagnosed with a stage 3, stage 4, or unstageable pressure injury? SATA a. Avoid prolonged elevation of the head of the bed b. Consider the use of a wheelchair cushion c. Order a standard hospital foam mattress d. Consider an alternating pressure support surface e. Place a pillow under the calves to decrease the risk of heel breakdown

a. Avoid prolonged elevation of the head of the bed b. Consider the use of a wheelchair cushion d. Consider an alternating pressure support surface e. Place a pillow under the calves to decrease the risk of heel breakdown

Which factor is true regarding the development of pressure injuries? SATA a. Chronic immobility can cause Pis b. Excessive moisture prevents pressure injuries c. Nutrition has no effect on pressure injury incidence d. Edema of the skin can cause pressure injuries e. Dehydration of the body can cause pressure injuries

a. Chronic immobility can cause Pis d. Edema of the skin can cause pressure injuries e. Dehydration of the body can cause pressure injuries

Which nursing action is intended to minimize patient pain when performing a wound care procedure? SATA a. Clipping any hair around the patient's wound b. Cleaning the patient's wound edges gently c. Turning and repositioning the patient carefully d. Administering analgesics as prescribed e. Removing tape from the patient's skin with force

a. Clipping any hair around the patient's wound b. Cleaning the patient's wound edges gently c. Turning and repositioning the patient carefully d. Administering analgesics as prescribed

Which nursing action would be a teaching strategy for patients and families who will be working with a pressure-redistribution surface? SATA a. Explaining the reasons for the prescription b. Teaching common errors associated with the prescription c. Noting the minimum layers of linins to be used with the prescription d. Asking the patients and caregivers to discuss possible sensations associated with the prescription e. Requesting a return demonstration of turning and repositioning techniques with the prescriptions

a. Explaining the reasons for the prescription b. Teaching common errors associated with the prescription c. Noting the minimum layers of linins to be used with the prescription Asking the patients and caregivers to discuss possible sensations associated with the prescription and requesting a return demonstration of turning and repositioning techniques with the prescriptions are examples of evaluation strategies

For which patient hypotheses would the nurse select turning and positioning as a solution? a. Impaired Skin Integrity b. Risk for Pressure Ulcer/Injury c. Malignant Wound d. Impaired Tissue Integrity e. Risk for Impaired Integrity

a. Impaired Skin Integrity b. Risk for Pressure Ulcer/Injury d. Impaired Tissue Integrity e. Risk for Impaired Integrity

Which nursing action would be appropriate when removing tape from a patient's wound care? SATA a. Loosen the ends b. Pull the tape in the direction of hair growth c. Use adhesive removed to loosen the tape d. Apply hard traction to the skin next to the wound e. Gently pull the outer end perpendicular to the skin surface

a. Loosen the ends b. Pull the tape in the direction of hair growth c. Use the adhesive remover to loosen the tape

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity? a. Low prealbumin levels b. Immobility c. Inexperience with wound cared. Stage 2 pressure injury e. Stage 4 pressure injury

a. Low prealbumin levels b. Immobility d. Stage 2 pressure injury

Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage? SATA a. Notify the primary health care provider b. Take the patient's temperature c. Review white blood cell count d. Chart the expected findings e. Apply steri-strips to the wound

a. Notify the primary health care provider b. Take the patient's temperature c. Review white blood cell count

Which intervention would be most effective for compromised skin integrity? a. Preventing breakdown b. Administering medication c. Implementing wound care d. Monitoring wound healing

a. Preventing breakdown

Which nursing intervention minimizes the risk of pressure injury development? SATA a. Repositioning the patient every 2 hours b. Using a drawsheet to assist with repositioning c. Conducting a nutritional assessment every 8 hours d. Applying barrier creams for patients who are incontinent e. Providing education related to preventing skin breakdown

a. Repositioning the patient every 2 hours b. Using a drawsheet to assist with repositioning d. Applying barrier creams for patients who are incontinent e. Providing education related to preventing skin breakdown

Which intervention would be part of the Nursing Intervention Classification (NIC) of pressure management? SATA a. Repositioning the patient every 90 minutes b. Irrigating the wound with a saline solution two times per day c. Avoiding the use of massage around the open area d. Dressing the area two times per day per provider prescription e. Elevating the head of the patient's bed to no more than 30 degrees

a. Repositioning the patient every 90 minutes c. Avoiding the use of massage around the open area e. Elevating the head of the patient's bed to no more than 30 degrees

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound? a. Repositioning the patient b. Administering medication for wound pain c. Assessing and evaluating a patient's skin and wounds d. Reporting any changes in patient's skin integrity or condition e. Applying a nonsterile dressing for chronic wounds with an established treatment plan

a. Repositioning the patientd. Reporting any changes in patient's skin integrity or conditione. Applying a nonsterile dressing for chronic wounds with an established treatment plan

Which result would be considered a benefit of using a binder over or around a dressing? SATA a. Securing a splint b. Reducing edema c. Allowing the body part freedom to move d. Creating pressure over the body part e. Preventing infection

a. Securing a splint b. Reducing edema d. Creating pressure over the body part

A patient has come to the clinic after sustaining an abrasion. Which characteristic of this wound type would the nurse likely find upon assessment? SATA a. Supeficial b. A partial-thickness wound c. Weepy appearance d. Profuse bleedinge. Increased risk of internal bleeding and infection

a. Supeficial b. A partial-thickness wound c. Weepy appearance

Which functions are associated with the integumentary system? a. Temperature regulation b. Protection from external elements c. Touch, smell, and taste sensations d. Excretion e. Synthesis of vitamin E

a. Temperature regulation b. Protection from external elements c. Touch, smell, and taste sensations d. Excretion

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days? a. Therapies consistent with guidelines for the treatment of wounds b. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) c. Ability of the patient to maintain a pain rating of 8/10 during activities of daily living d. Agreement of the patient with the treatment plan e. Capability of the patient to purchase supplies for home care as required

a. Therapies consistent with guidelines for the treatment of wounds b. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) d. Agreement of the patient with the treatment plan e. Capability of the patient to purchase supplies for home care as required

Which factor increases the risk of injury when applying heat therapy to a wound for a pediatric patient? a. Thinner layers of skin b. Alteration in nerve pathways c. Rupture and systemic infection d. Decreased peripheral circulation

a. Thinner layers of skin

The removal of devitalized tissue from a wound describes which process?a. debridement b. pressure reduction c. negative pressure wound therapy d. sanitization

a. debridement

Which condition warrants the use of cold therapy? a. direct trauma b. rectal surgery c. painful hemorrhoids d. vaginal inflammation

a. direct trauma

Which prescription might the nurse anticipate for a patient with new-onset bowel incontinence that is causing compromised skin integrity? a. New prescription for a diuretic b. A change in dietary prescription c. The implementation of timed voiding d. The implementation of physical therapy

b. A change in dietary prescription a new prescription for a diuretic is most appropriate to increase urinary output. The implementation of timed voiding is appropriate for urinary inconctinence. The implementation of PT would be appropriate for patients with impaired mobility.

The nurse is providing care to a patient with a pressure injury that is covered in eschar. Which dressing prescription will the nurse use for this patient?a. None b. Adherent film c. Composite film d. Calcium alginate

b. Adherent film

The nurse is applying negative pressure therapy to a wound near the sacrum. Which intervention by the nurse is most beneficial to the patient in this situation? SATA a. Using adhesive remover b. Clipping hair around the wound c. Avoiding wrinkles in the transparent film d. Cutting the transparent film about 5 cm beyond the wound's edges e. Avoiding the use of multiple small strips of transparent

b. Clipping hair around the wound c. Avoiding wrinkles in the transparent film d. Cutting the transparent film about 5 cm beyond the wound's edges

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? a. Binder b. Ice bag c. Elastic bandage d. Absorptive diaper

b. Ice bag

A patient with limited mobility develops to stage 3 sacral pressure injury. Which nursing intervention is appropriate for reducing the risk of wound infection in this patient? SATA a. Obtaining a wound culture as needed b. Irrigating and cleansing the wound with saline twice a day c. Repositioning the patient at least every 90 minutes d. Packing the open wound with antibiotic solution-moistened gauze e. Requesting a prescription for a prophylactic antibiotic

b. Irrigating and cleansing the wound with saline twice a day d. Packing the open wound with antibiotic solution-moistened gauze

Which nursing intervention would be appropriate for a patient who is at risk of infection because of a surgical incision at the right hip? a. Applying moisture barrier cream b. Obtaining a wound culture as needed c. Providing analgesics before wound care d. Using correct repositioning techniques

b. Obtaining a wound culture as needed

Which intervention is appropriate for a patient who is at risk of skin breakdown because of decreased sensory perception? a. Keep the skin dry and free of maceration b. Provide a pressure-redistribution surface c. Consult a dietician for nutritional assessment d. Provide a trapeze to facilitate movement in bed

b. Provide a pressure-redistribution surface Trapeze is for a patient who is at risk of skin breakdown due to friction and shear

Which intervention would the nurse implement when providing care to a patient at risk of skin breakdown because of urinary incontinence? SATA a. Provide adequate fluid intake b. Reposition the patient off at-risk areas often c. Apply a moisture-barrier ointment d. Cleanse the perineal area with a no-rinse cleaner e. Protect pressure points from medical devices

b. Reposition the patient off at-risk areas often c. Apply a moisture-barrier ointment d. Cleanse the perineal area with a no-rinse cleaner

3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? a. The patient ate two thirds of breakfast b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.

b. The patient has fecal incontinence.

Which patient statement indicates understanding of the disadvantages of using moist applications for wound therapy? a. Increases body fluid loss b. causes maceration of the skin c. Causes increased drying of the skin d. It does not penetrate deep into tissues

b. causes maceration of the skin

Which characteristic would be present in a stage 3 pressure injury? a. underlying muscle is exposed b. slough may be present, but it does not obscure the depth of tissue loss c. Discoloration of the skin , warmth, edema, hardness, and/or pain may be present d. it presents as a shallow, open, ulcer with a red-pink wound bed without slough

b. slough may be present, but it does not obscure the depth of tissue loss

Which equipment would the nurse have available when irrigating a surgical wound? a. Catheter tip 20 ml syringe b. Catheter tip 60 ml syringe c. 35-ml syringe with a 19 guage soft angiocatheterd. 20 ml syringe with a 17 gauge soft angiocatheter

c. 35-ml syringe with a 19 gauge soft angiocatheter

Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement? a. Sharp b. Biologic c. Autolytic d. Mechanical

c. Autolytic

A patient with multiple fractures has casts that make it difficult to move voluntarily. Which measure would the nurse take to decrease the risk of developing pressure injuries in this patient? SATA a. Position the patient in the most comfortable position and do not move b. Cover the hyperemic skin area with a sterile dressing and apply antiseptics c. Check the skin around the casts regularly for any signs of deteriorated skin condition d. Take care to avoid friction injuries during repositioning, bathing, or transferring of the patient e. Use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements

c. Check the skin around the casts regularly for any signs of deteriorated skin condition d. Take care to avoid friction injuries during repositioning, bathing, or transferring of the patient e. Use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements

43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement? a. Monitor vital signs every 15 minutes. b. Apply brace to the right knee. c. Elevate the right knee and apply ice .d. Check pulses in the right foot.

c. Elevate the right knee and apply ice Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part

Which technique would the nurse use to turn a patient? a. Place patient's head of bed at 90 degrees. b. Place pillows to let patient's heels touch bed. c. Position patient's body laterally at 30 degrees. d. Position towels between bed and patient's knees

c. Position patient's body laterally at 30 degrees.

Which statement is true about wet-to-dry dressings for mechanical debridement of a wound? a. remove when partially dry b. apply completely wet c. apply moist, not wet d. leave in place for at least 12 hours

c. apply moist, not wet

Which adjuvant treatment is only considered for patients diagnosed with clean stage 4 or unstageable pressure injuries? SATA a. support hydration b. nutrition support c. surgical consultation for closure d. surgical consultation for debridement e. evaluation of pressure-redistribution needs

c. surgical consultation for closure --> stage 4 d. surgical consultation for debridement --> Unstageable

25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? Use a low-air-loss therapy unit. Consult a dietitian. Irrigate with hydrogen peroxide. Utilize hydrogel dressing.

clean, granulating wound --> Irrigate with hydrogen peroxide. clean Pressure Injury --> normal saline

When performing any wound care procedure, when would the nurse administer pain medication to address the patient's pain and discomfort? a. After the procedure b. At the beginning of the procedure c. 10-20 minutes before the procedure d. 30-60 minutes before the procedure

d. 30-60 minutes before the procedure

Which patient situation is an example of friction? a. A patient sitting up in bed b. A patient who has diabetes c. A patient lying in the same position for 4 hours d. A patient's leg rubbing against the side rail of a bed

d. A patient's leg rubbing against the side rail of a bed

The nurs is preparing a care plan for a patient who has a pressure injury on the coccyx. Which part of the plan is included to provide comfort to the patient? a. Repositioning every 90 minutes b. Cleaning and massaging around the affected area c. Elevating the head of the patient's bed to 30 degrees d. Applying a moisture barrier ointment over the injury

d. Applying a moisture barrier ointment over the injury

The nurse is changing the dressing of a patient with a drain placed at the surgical site. The nurse notices that the collecting device has minimal drainage, much less than expected. Which inference would the nurse suspect based on this observation? a. accelerated wound healing b. need for advancing the drain c. Dislodged tube of the drain d. Blockage in the drainage tube

d. Blockage in the drainage tube

Which patient would be at risk of systemic infection if heat is applied as a form of therapy? a. pediatric patient b. patient with a spinal cord injury c. Patient with atherosclerosis d. Patient with an abscessed tooth

d. Patient with an abscessed tooth

The nurse obtains an air-filled overlay for a patient's bed who is at risk of pressure injuries. Which advantage would this intervention offer this patient?a. Encourages movement b. Keeps the skin cool and dry c. Reduces friction and pulling on the skin d. Redistributes pressure

d. Redistributes pressure

Which action would the nurse take for a patient with a hypothesis of Impaired Skin Integrity? a. Raise head of bed to 45 degrees. b. Offer a low-protein diet. c. Lightly massage the injured area. d. Suggest increasing fluid intake.

d. Suggest increasing fluid intake.

The absence of adequate amounts of which nutrient in the diet may impair inflammatory response and wound healing? Zinc proteins vitamin A vitamin C

vitamin A

Which intervention with the nurse plan for a patient who has a sacral pressure injury? Apply a moisture barrier to the wound at least twice daily Administer an analgesic 15 minutes before repositioning and wound care When the patient is lying down position him or her in a 45° lateral position Pack open areas of the wound with gauze moistened with an antibiotic solution

Pack open areas of the wound with gauze moistened with an antibiotic solution

Which assessment technique indicates a nurse properly determines if the patient incision is healing or is becoming infected Asking the patient health history questions Charting the incision lines color and tenderness Removing all sutures and/or staples around the wound Palpating the area of induration around the incision line

Palpating the area of induration around the incision line

Which patient is likely at risk for developing a pressure injury Patient with unrelieved pressure who has a fractured hip Patient with a history of sports related injuries and concussions Left-handed patient with a broken left wrist Paralyzed patient who is being turned and repositioned every two hours

Patient with unrelieved pressure who has a fractured hip

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident? Patient's pressure injury will decrease at least 1 to 2 cm in size per week. Patient's wound will exhibit granulation tissue in the wound by 1 week. Patient will demonstrate wound care after receiving teaching. Patient will have intact skin throughout hospital stay.

Patient's wound will exhibit granulation tissue in the wound by 1 week.

The nurse performs the skin and risk assessment on a patient who is diabetes in limited mobility because of a fractured left hip and finds that the skin is intact without any skin disintegration. Which nursing intervention with the nurse provide to the patient? Place a pillow under the patient's calves Position the patient at a 30° medial turn Use standard hospital foam mattresses for the patient Recommend alternating pressure support surfaces for the patient

Place a pillow under the patient's calves

2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is Pressure. Resistance. Stress. Weight.

Pressure.

10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by Tertiary intention. Secondary intention. Partial-thickness repair. Primary intention.

Primary intention.

28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patients willingness and ability to increase mobility, which intervention is most important for the nurse to complete? Encourage the patient to sit up in the chair. Provide analgesic medication as ordered. Explain the risks of immobility to the patient. Turn the patient every 3 hours while in bed.

Provide analgesic medication as ordered.

21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? Don sterile gloves. Provide analgesic medications as ordered. Avoid accidentally removing the drain. Gather supplies.

Provide analgesic medications as ordered.

Which cue alerts the nurse that a patient receiving cold therapy is improving? Edema Psychological relaxation Increased blood flow to area Relief from muscle spasms

Relief from muscle spasms

When would an application of a warm moist compress be indicated select all that apply Relieve edema Reduce shivering Improve blood flow to an injured part Protect bony prominences from pressure injuries Promote consolidation of purulent drainage

Relieve edema Improve blood flow to an injured part Promote consolidation of purulent drainage

12. Which nursing observation would indicate that a wound healed by secondary intention? Minimal scar tissue Minimal loss of tissue function Permanent dark redness at the site Scarring can be severe.

Scarring can be severe.

11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by Tertiary intention. Secondary intention. Partial-thickness repair. Primary intention.

Secondary intention. - laceration, burn, pressure ulcer, surgical wound that is contaminated or has tissue loss

Which factors may impact the development of pressure injuries or nonhealing wound wounds Smoking diabetes specific gender urinary incontinence skin tone

Smoking diabetes urinary incontinence