VSim for week three

The nurse assesses a wound and documents it as stage III. What did the nurse observe when the wound was assessed

Full thickness tissue loss with possible visible subcutaneous fat.

Stave IV pressure ulcer

Has full thickness tissue loss with exposed bone, tendon or muscle

Stage I pressure ulcer

Has intact skin with nonblanchable redness of localized area

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 on inch from the upper tip of the wound

Why is it necessary to irrigate a wound

Irrigation helps remove drainage and debris from the wound.

Dakin solution

Is used with wounds that have necrotic tissue

Nurse is preparing to irrigate a patients wound, upon assessment the wound appears to be healing and the wound bed is beefy red. What solution should the nurse select for this procedure?

Normal saline

When performing an assessment on a wound what should be included in documentation?

Odor, Location, Drainage, Tunneling

Hydrocolloid dressings

They are self adhesive and they help maintain a moist wound environment, can be left in place for three to seven days and help protect wounds from contamination

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

Purulent- yellow foul drainage Serous drainage- clear and watery Sanguineous is bring red and looks like blood Serosanguineous is light pink to blood tinged

The nurse is completing an admission assessment on a patient admitted for an infected, non healing wound. What are factors that could contribute to this condition?

Diabetes mellitus, Obesity, Poor circulation, Poor hygiene

Stage II pressure ulcer

Has partial thickness loss of dermis presenting as a shallow open ulcer with red/pink wound bed

The nurse is reviewing the patients laboratory results. Which lab test most accurately represent current nutritional status?

Prealbumin- has a shorter half life and is more sensitive measurement of current nutritional status

Nurse is irrigating a patients wound when the patient complains of pain what is the appropriate action by the nurse?

Stop the procedure and administer ordered analgesic.

The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. What question would be appropriate for the nurse to ask the patient

-Have you noticed any swelling on your feet, ankles or fingers - do you have some areas of your skin that seem warmer or colder than others - have you used pads of special pants because you cant control your urine - do you have any sores on your body

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 nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg

Dark discoloration of the skin surrounding the wound site. shiny skin on lower extremities with hair loss would be indicative of peripheral arterial disease. Pale white toes and decreased sensation are descriptive of Reynauds disease.

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

High risk. 10-12 score is high risk. 19-23 is not a risk 15-18 is low risk 13-14 is moderate risk

Nurse providing education to a patient and daughter on management of venous stasis in the lower extremities. What would be appropriate for the nurse to include in the teaching session

Put on antiembolism stockings as soon as you get up in the morning and wear them all day. The patient should elevate her legs to facilitate venous return to the heart, skin should be kept moist and should be inspected daily and patients should participate in an individualized walking program

Nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the care of plan for this patient?

The nurse should provide skin care, monitor for signs of skin breakdown, assist with rang of motion exercises, and perform neurovascular checks. The nurse would encourage ambulation as tolerated

The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history

When did the edema start? -Can you describe the edema? - What were you doing just before you noticed the edema? -Do you have a recent history of surgery or illness? -What are your usual daily activities? -Do you stand alot? -What medications do you take? -Do you have heart disease or blood vessel disease