Lewis Wound NCLEX
An 85 year-old patient is assessed to have a score of 16 on the Braden scale.Based on this information, how should the nurse plan for this patient's care? A. implement a q2h turning schedule with skin assessment B. place a DuoDerm on the patient's sacrum to prevent breakdown C. elevate the head of the bed to 90* when the patient is supine D. continue weekly skin assessments with no extra precautions
A
A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? A. tertiary intention B. secondary intention C. regeneration of cells D. remodeling of tissue
B
Which of the following orders should a nurse question as part of the plan of care for a patient with a stage III pressure ulcer? A. pack the ulcer with foam dressing B. turn and reposition the patient every 2 hours C. clean the ulcer every shift with Dakin's solution D. assess for pain and medicate before dressing change
C
A nurse is caring for a patient with diabetes and a necrotic left greater toe who is scheduled for amputation of the affected toe. The patient's WBC count is 15x10^6/uL, and he has coolness of the lower extremities, weighs 75 lbs more than his ideal body weight, and smokes 2 packs of cigarettes a day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? A. imbalanced nutrition: more than body requirements related to high-fat foods B. impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking C. ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking D. ineffective individual coping related to lack of regard and denial of the long-term effects of diabetes and smoking
B
A patient is 1 day postoperative after having abdominal surgery, she has incisional pain, a 99.5*F temp, slight erythema at the incision margins, and 30mL of serous sanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make? A. the abdominal incision is showing signs of infection B. the patient is experiencing a normal inflammatory response C. the abdominal incision is showing signs of impending dehiscence D. the patient's physician needs to be notified of the patient's condition
B
A patient is admitted to the medical unit with a 103.7*F temperature. Which of the following would be most effective in restoring normal body temperature? A. use a cooling blanket while the patient is febrile B. administer antipyretics on a round-the-clock schedule C. provide increased fluids and have the NAP give sponge baths D. give prescribed antibiotics and provide warm blankets for comfort.
B
A patient is admitted with a chronic leg wound. The nurse assess local manifestations of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? A. serum protein analysis B. WBC count with differential C. punch biopsy of center of wound D. culture and sensitivity of the wound
B
A 65 year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which of the following nursing diagnoses are appropriate (select all that apply): A. acute pain related to tissue damage and inflammation B. impaired skin integrity related to immobility and decreased sensation C. impaired tissue integrity related to inadequate circulation secondary to pressure D. risk for infection related to loss of tissue integrity and undernutrition secondary to stroke
B, C
An 82 year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1cm x 2cm x 0.8cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? A. Stage I B. Stage II C. Stage III D. Stage IV
C
