wound care pretest

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?

alginate

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 clients pressure injury?

barrier creams barrier creams and ointments are used for clients that are prone to skin breakdown from pressure, shear, or incontinence. Therefore, the nurse should plan to apply barrier creams for a client who has a stage 1 pressure injury.

a nurse is caring for a client who has 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?

pulsating lavage pulsating lavage or irrigation provides mechanical debridement by dislodging exudate, debris, and necrotic tissue in the wound bed.

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?

corticosteroids corticosteroids supress the immune system and all can therefore delay wound healing

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 dressing should the nurse select to help minimize the pain of dressing changes?

hydrogel the nurse should select hydrogel for this client because hydrogel does not adhere to the wound bed and maintains moisture, which result in decreased pain

a nurse is documenting data about a healing wound on a clients 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 this exudate is serosanguineous, which is thin and waterey in consistency and pink to light color

a nurse is documenting data about a deep necrotic wound on a clients 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?

slough slough is stringy necrotic tissue that appears whitish, yellowish, or tan in color and is firmly attached to the wound bed. the nurse should document this finding for the client

a nurse is staging a pressure injury over a clients right heel are. 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?

stage 3 the nurse should identify that this client has a stage 3 pressure injury indicated by full-thickness tissue loss appearing as a deep crater, without exposed muscle or bone. stage 3 pressure can have slough, but is not necessary.