Pearson Wound Healing

The nurse is providing teaching about wound care at home to the family of an older patient who had surgery yesterday. Which information should the nurse include about preventing skin tears during dressing changes?

it is important to hold the skin taut during application of the dressing.

The nurse is providing discharge teaching for an older patient who will be recovering surgery at home. Which patient statement demonstrates an understanding of measures to promote wound healing?

"I will make sure I take the nutritional supplements that the dietitian recommended."

The nurse is providing discharge instructions to a patient with diabetic ulcers on both heels. Which statement should the nurse include?

"Keeping the wound bed moist with each dressing change will help facilitate healing."

The graduate nurse is caring for a patient who has been admitted to the hospital for major abdominal surgery and will have a lengthy stay. Which statement by the graduate nurse to the preceptor demonstrates a need for additional teaching regarding the promotion of optimal nutrition?

"i will make the menus for the patient while they are an inpatient.

A patient presents with a severe sunburn and asks the nurse if there are any alternative therapies to help heal the sunburn. Which therapy should the nurse suggest that is supported by evidence-based research

Aloe vera

The nurse is caring for a patient with a large infected wound. How much fluid should the nurse encourage the patient to take daily to aid in wound healing?

At least 2500 mL

The nurse is providing wound care to a patient who is who had abdominal surgery earlier in the day. The nurse observes a scant amount of blood on the dressing. Which action should the nurse implement?

Document the amount of blood on the wound dressing

The nurse is caring for a patient who received full thickness burns to the upper body. The wound has a copious amount of thick, black tissue causing circumferential constriction of the patient's torso. Which collaborative therapy should the nurse anticipate first for the patient?

Escharotomy

A patient is admitted for an exploratory laparotomy for abdominal pain. Which information in the patient's medical history will be important for the nurse to consider when assessing the likelihood of developing a skin disorder?

Family member with the skin disorder

The nurse assessing a patient who is diabetic and had abdominal surgery 4 days ago observes a separation of the proximal wound edges by 1.6 cm. Which action is the nurse's priority?

Notifying the healthcare provider

The nurse is assessing the healing of a patient's wound. Which clinical manifestations should the nurse consider to determine that the patient has entered the inflammatory phase of wound healing?

Redness, heat, pain, and swelling at the site

The nurse is planning to discharge an older patient with right side paralysis who will be cared for at home by his daughter. The patient currently has a wound on their coccyx. Which is the most important information to include in the discharge teaching

Repositioning at least every 2 hours

The nurse is caring for an older patient who has with right-sided paralysis and a deep sacral wound. The unlicensed assistive personnel (UAP) asks the nurse why it is important to reposition the patient every 2 hours. Which is the best response by the nurse?

Repositioning every 2 hours will relieve the pressure and prevent further tissue damage."

The nurse identifies an alteration in tissue integrity in a patient with a foot wound. Which intervention should the nurse include when caring for this patient?

Teaching the signs of wound infection

The nurse is discussing with colleagues the differences between wound healing by primary versus secondary intention. Which statement by the nurse is accurate with regard to primary intention healing?

The best example of primary intention wound healing is a closed surgical wound.

A patient with a wound infection has been receiving an oral antibiotic. Which information is most important for the nurse to communicate to the healthcare provider?

The lab report shows sensitivity to a different antibiotic.

The nurse is admitting a patient with deep wounds on both heels. Which information obtained by the nurse will have the most impact on wound healing?

The patient takes insulin daily

The nurse is preparing the discharge instructions about wound care at home for the parents of a school-aged child who had an open appendectomy this morning. Which information is important for the nurse to include in the discharge instructions?

Washing hands and wearing gloves before touching the wound

A patient who had abdominal surgery 1 week prior has a temperature of 102.5° F (39.2° C). The patient's wound is draining a yellowish exudate and the surrounding skin is warm to the touch. The nurse receives an order for a culture and sensitivity of the drainage. Which statement reflects the nurse's correct understanding of what this test will indicate?

Which antibiotic will be most effective

A post-operative patient has an incision with staples in the right groin. The nurse assesses swelling around the incision and notes that the right thigh is noticeably larger than the left. The patient is pale and diaphoretic with a blood pressure of 72/48 mmHg. Which complication should the nurse suspect?

Hemorrhage

The nurse is caring for a patient admitted for an emergency appendectomy 12 hours prior. The dressing over the wound is assessed and is 50% saturated with drainage. Which documentation by the nurse best describes the wound assessment?

Moderate drainage

The home care nurse is visiting an older patient who has a large nonhealing wound on her lower leg. The patient states, "I have a hard time cooking so I usually just heat up something quick." Which deficiency in the diet that can affect healing is this patient at risk for?

Protein

A woman underwent a left mastectomy 2 days ago. Which factor should the nurse consider will put the patient at the highest risk for developing a wound infection?

Starting chemotherapy in one week

The nurse is completing the skin assessment for a patient with a wound that includes the presence of necrotic tissue. Which treatment should the nurse anticipate be ordered for this patient

Surgical debridement

A patient is being assessed by the healthcare provider for potential therapies for a sternal wound. One therapy under consideration is biosurgery. Which observation should the nurse expect while examining the wound?

The wound will have necrotic tissue or slough

The nurse is admitting an older patient from a long-term care facilty who has a wound on their coccyx. The nurse should determine that which factor is associated with the development of this wound?

Thinning skin and loss of subcutaneous tissue

The nurse is assessing the skin of an older patient for skin tears. The nurse should understand that which intervention can increase the the patient's risk for skin tears?

Using adhesive tape

A patient presents with signs of a wound infection. Which diagnostic test should the nurse expect to be ordered to determine the antibiotic choice?

Culture and Sensitivity

A nurse is admitting a patient who is paraplegic with a wound on the coccyx. Based on the health history, the nurse should determine that which factor had the greatest impact on wound development?

Inability to reposition frequently

The nurse is assessing for a patient with diabetes who had abdominal surgery 3 days prior. Which finding is a priority for the nurse to report to the healthcare provider

Separation of the proximal wound edges by 1.5 cm