Skin Integrity EAQ's

The nurse manager implements a change in the back care routine provided to bedridden clients to help prevent pressure ulcers. The nurse manager observes a decrease in the incidences of pressure ulcers in the unit and appreciates the efforts of the team members who implemented the change. Which step of Kotter's eight-step change model is reflected in this scenario?

Anchoring the changes in the culture

How would the nurse describe the exudate characteristic of a serosanguineous wound?

Blood-tinged amber fluid

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what?

Causing local vasoconstriction, preventing edema and muscle spasms

What is the etiology for the development of pressure ulcers in an 80-year-old client?

Decreased subcutaneous fat

A primary healthcare provider is treating the red-color wound of a client caused by pressure ulcers. Which dressings are beneficial for wound recovery? Select all that apply.

Hydrocolloid dressings Transparent film dressings Telfa dressings with antibiotic ointment

Which functions does the nurse associate with the epidermis? Select all that apply.

Inhibits proliferation of microorganisms Allows the photoconversion of 7-dehydrocholesterol to vitamin D

Which dressing technique for wound debridement would be most effective for spontaneous separation of the necrotic tissue to prevent the client from developing an infection?

Moisture-retentive dressing

Which key feature does the nurse associate with a stage 2 pressure ulcer?

Presence of nonintact skin

What is the function of the dermis?

Provides cells for wound healing

The primary healthcare provider treats a client with a pressure ulcer. While assessing the client, the nurse identifies exposed bone and tendons. Which stage does the nurse document for this pressure ulcer?

Stage IV

Which type of debridement is most often used to quickly remove large amounts of a client's nonviable tissue?

Surgical debridement

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action?

Turn and reposition the client every 2 hours.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?

Unstageable

The nurse teaches a client about cleaning the skin to prevent pressure ulcers. Which statement made by the client indicates the nurse needs to follow up?

"I should apply powders or talc on a perineum wound."

A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching?

"I should not worry about what the client eats."

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply.

"I will elevate the head of the client's bed to no more than 30 degrees." "I will ensure that the client is turned and repositioned at least every two hours." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day."

A nurse is caring for a client who had major abdominal surgery one day ago. What factor increases the risk of this client developing a wound dehiscence?

Client being overweight

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers?

Frequent repositioning of client

What is the mechanism of action for wet-to-damp saline-moistened gauze for wound debridement?

Removing the necrotic tissue mechanically

A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing?

Vitamin C is required for collagen production by fibroblasts.