Wound Care
A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis? -Transparent -Hydrogel -Alginate -Dry gauze
Alginate
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care? -Leave nonbleeding wounds open to the air. -Administer a corticosteroid medication. -Initiate mechanical debridement. -Apply oxygen at 2 L/min via nasal cannula.
Apply oxygen at 2 L/min via nasal cannula.
A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the client's pressure injury? -Barrier creams -Antifungal ointment -Chemical debridement agent -Antibiotic agent
Barrier creams
A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? -Tricyclic antidepressants -Corticosteroids -Beta blockers -Anticholinergics
Corticosteroids
A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? -Wet-to-dry -Abdominal pads (ABD) -Dry gauze -Hydrogel
Hydrogel
A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive? -Placing a transparent dressing over the pressure injury -Applying hydrocolloids to the wound bed -Pulsating lavage -Using a topical enzyme solution in the wound bed
Pulsating lavage
A nurse is documenting data about a healing wound on a client's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document which of the following types of wound drainage? -Serosanguineous -Sanguineous -Serous -Purulent
Serosanguineous
A nurse is documenting data about a deep necrotic wound on a client's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document? -Keloid -Slough -Granulation -Eschar
Slough
A nurse is staging a pressure injury over a client's right heel area. The pressure injury has no eschar or slough and no exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following? -Unstageable -A suspected deep tissue injury -Stage 4 -Stage 3
Stage 3