vSim #6 - Josephine Morrow

The nurse knows ____ will help promote ____, leading to improvements in Josephine Morrow's wound healing.

applying compression stockings, venous return

When performing wound irrigation, the nurse understands to include which of the following during implementation of the procedure?

Assess the client's pain level during irrigation Apply gown, gloves, and mask with goggles Dry intact skin prior to applying dressing Assess wound bed for appearance

Following the review of Josephine Morrow's medical record, the nurse recognizes which of the following assessment(s) are part of her focused assessment?

Vital signs Pain Peripheral pulse Wounf assessment

The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12?

High risk

The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. When assessing the wound, the nurse will include which of the following?

Length, width, and depth in centimeters Condition of surrounding skin Presence of undermining or tunneling

The nurse is reviewing Josephine Morrow's medical records before initiating her plan of care. Which of the following factor(s) contributed to the development of her venous stasis ulcer?

Poor circulation Obesity Poor hygiene Poor nutrition

The nurse is reviewing a patient's laboratory results to determine the current nutritional status. Which of the following will negatively affect wound healing?

Protein deficiency Vitamin B excess

Following the wound irrigation and dressing change, the nurse begins client education regarding improving circulation. Which of the following response(s) from Josephine Morrow indicate the need for further teaching?

'I should inspect skin surrounding the wound at least once a week.' 'I should sit with my legs in the dependent position so that blood will drain to my lower extremities.' 'I should avoid ambulating, because it may aggravate my condition.' 'I need to limit my protein intake to help healing.'

Which of the following sign(s) and symptom(s) would the nurse expect in a patient with chronic venous insufficiency?

Wound exudate Lower extremity edema

The nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time?

Ask the patient to press the call bell to summon a co-worker to obtain another dressing.

The home health nurse is completing an admission assessment on a patient admitted for impaired skin integrity. Which question(s) would be appropriate for the nurse to ask the patient?

"Have you used pads or special pants because you can't control your urine?" "Do you have any sores on your body?" "Do some areas of your skin seem warmer or colder than others?" "Have you noticed any swelling on your feet, ankles, or fingers?"

The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure?

"I will gently direct a stream of fluid into the wound, keeping the syringe tip at least 1 inch from the upper tip of the wound."

The nurse removes a dressing and assesses yellow, foul-smelling drainage. How would the nurse document this finding?

Purulent

The nurse is preparing to irrigate Josephine Morrow's wound. Upon wound assessment, the nurse will most likely consider that which of the following indicate poor wound healing?

Creamy, yellow, purulent drainage Persistent tunneling A 2 mm increase in wound length Black, avascular tissue