Skin Integrity And Wound Care: Implement And Take Action; Evaluate

Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)?

Monitor for granulation tissue in the wound. Avoid using NPWT for a patient with a cancerous wound. If the patient reports pain, change from the black foam to white foam. Report to the health care provider if there is an increase in wound drainage.

Which evaluative cue would alert the nurse that a patient with a pressure injury is declining?

Braden Scale score was a 9 but is now an 8.

Which items would the nurse obtain to initiate vacuum-assisted wound closure for a patient?

Clear adhesive drape Suction tubing Foam sponge Negative-pressure setting device

Which food would the nurse suggest the patient consume to increase zinc in the diet for wound healing?

Fish

Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of wound drainage?

Foam

Which patient scenario would prompt the nurse to question a prescription for cold therapy?

Has edema present

Which solution would the nurse obtain to clean a patient's arm wound?

Normal saline

Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage?

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

Which actions would the nurse take for a patient receiving heat therapy?

Obtain distilled water for aquathermia treatments. Check on the disoriented patient more frequently. Cover the container and hand when providing warm hand soaks.

Which technique would the nurse use to turn a patient?

Position patient's body laterally at 30 degrees.

Which action by the nurse is priority when providing discharge teaching to a patient and spouse about wound care when the spouse is the primary caregiver?

Provide written instructions

Which action would the nurse take when caring for a patient's Jackson-Pratt drain?

Reactivate the drain after emptying.

Which cue alerts the nurse that a patient receiving cold therapy is improving?

Relief from muscle spasms

Which action would the nurse take when placing noncommercial ice packs on a patient's injured shoulder?

Remove air from the pack before closing.

Which piece of equipment would the nurse likely obtain for a patient who has a prescription for therapy that is primarily heat only?

Sitz bath

Which action would the nurse take for a patient with a hypothesis of Impaired Skin Integrity?

Suggest increasing fluid intake

Which statement indicates the nurse has a correct understanding of a patient's pressure-reducing bed?

The support surface may be foam or gel

Which actions would the nurse take for a comatose patient who has frequent liquid stools and has a Braden Scale score of 8?

Turn the patient every 2 hours for repositioning. Pad and protect any bony prominences. Wash and dry the patient's skin after each liquid stool.

After receiving report, the nurse would delegate which tasks to the unlicensed assistive personnel?

Turning a patient with a pressure injury Cleaning an incontinent patient of stool and urine

Which parameters would the nurse include when charting about a patient's warm compress on the left leg?

Type of therapy Length of therapy Type of drainage

Which foods would the nurse recommend for a patient with a leg wound who needs to increase vitamin A intake?

carrots sweet potatoes

Which action for skin hygiene would the nurse take for an obese patient who is immobile?

Keep skinfolds dry from perspiration.

Which intervention would the nurse implement for a patient with an open drain?

Keep the safety pin in place

Which statement indicates the nurse has a correct understanding about the different types of patient dressings?

"I will avoid using hydrocolloids for infected wounds."

Using military time, at what time would the nurse turn the patient if the patient was last turned at 1 p.m.? Record your answer as a whole number. __

1500

Which patient situations would prompt the nurse to question a prescription for heat therapy?

A patient with a local tooth abscess A patient with possible appendicitis rupture. A patient with bleeding from a small wound

Which action would the nurse take for a mother who calls the clinic reporting that a thick yellowish drainage is leaking out of her daughter's surgical leg incision and the incision edges are red and warm?

Ask the mother to bring her daughter to the office to be evaluated by the surgeon immediately.

Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement?

Autolytic

Which techniques would the nurse use to troubleshoot issues with patients' dressings?

Use an abdominal binder to help a patient who has an abdominal wound to cough. Use Montgomery straps for a patient who needs frequent dressing changes. Use a splint to help a patient who has an abdominal incision to deep breathe.

Which action would the nurse take when irrigating a patient's abdominal wound?

Use sterile technique

Match the type of wrap the nurse would use for each injured body part.

extremities: spiral joint: figure 8 head: recurrent

Which parameters would the nurse monitor after applying a wrap to an ankle?

pain pallor paralysis paresthesia pulselessness

Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with minimal drainage?

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