Tissue Integrity Test 6

Which statement is true regarding sutures? 1 Fine sutures cause minimal tissue injury. 2 Deep sutures are composed of nonabsorbable material. 3 Continuous sutures are least likely to cause inflammation. 4 Retention sutures are placed more superficially than skin sutures

1 Fine sutures cause minimal tissue injury.

Which dressing is appropriate for a patient with a clean stage II pressure ulcer? 1 Gauze 2 Hydrogel 3 Transparent 4 Hydrocolloid

1 Gauze 2 Hydrogel 4 Hydrocolloid

Which dressings are inappropriate for intact stage I pressure ulcers? Select all that apply. 1 Gauze 2 Transparent 3 Hydrocolloid 4 Composite film 5 Calcium alginate

1 Gauze 4 Composite film 5 Calcium alginate

What are the implications for healing of a surgical incision? Select all that apply. 1 Heals by epithelialization 2 Lacks wound contraction 3 Clean and intact wound edges 4 Lacks granulation tissue formation 5 Heals quickly with minimal scar formation

1 Heals by epithelialization 3 Clean and intact wound edges 5 Heals quickly with minimal scar formation

Which type of dressing is preferred for dry wounds? 1 Hydrogel 2 Hydrocolloid 3 Calcium alginate 4 Debriding enzymes

1 Hydrogel

What size syringe is used for irrigating an open wound? Record your answer using whole number. _______ mL

35 mL

The registered nurse is teaching a nursing student about home care considerations to prevent the risk of pressure ulcers. Which statements made by the nursing student indicate effective learning? Select all that apply. 1 "I should educate the patient about the signs of wound infection." 2 "I should discuss reactive surfaces that may increase pressure to the wound." 3 "I should instruct the patient to dispose of the soiled dressings by incineration." 4 "I should instruct the patient to evaluate the healing by using the pressure ulcer staging system." 5 "I should instruct the patient to approach the registered nurse if the wound does not heal within 2 weeks."

1 "I should educate the patient about the signs of wound infection." 2 "I should discuss reactive surfaces that may increase pressure to the wound."

Which patient statement indicates understanding of the disadvantages of using dry applications for wound therapy? 1 "It increases body fluid loss." 2 "It causes maceration of the skin." 3 "It causes increased drying of the skin." 4 "It does not penetrate deep into tissues.

1 "It increases body fluid loss." 3 "It causes increased drying of the skin." 4 "It does not penetrate deep into tissues.

What type of wound drainage is considered sanguineous? 1 Clear, watery plasma 2 Bright red, active bleeding 3 Thick and yellow, green, tan, or brown 4 Pale pink, watery mixture of clear and red fluid

2 Bright red, active bleeding

The nursing instructor is discussing the Braden Scale for pressure ulcer development risk with a nursing student. Which of the student's statements is incorrect? 1 "The Braden Scale has shown sufficient predictive validity and accuracy for all patients." 2 "The Braden Scale was developed based on risk factors in a nursing home population." 3 "The Braden Scale contains six subscales, and the total score ranges from 6 to 23." 4 "The Braden Scale is the most widely used risk assessment tool for pressure ulcers."

1 "The Braden Scale has shown sufficient predictive validity and accuracy for all patients."

What amount of protein per kilogram of body weight a day should the nurse recommend a patient consume to support wound healing? 1 1.25 to 1.5 g 2 2 to 3.5 g 3 3.5 to 4.5 g 4 5.15 to 6.5 g

1 1.25 to 1.5 g

What amount of zinc is recommended for wound healing? 1 15-30 mg 2 30-50 mg 3 25-60 mg 4 50-70 mg

1 15-30 mg

Which patients are at risk of developing pressure ulcers? Select all that apply. 1 A patient who has urinary incontinence 2 A patient who has had hip replacement surgery 3 A patient who walks with the help of an assistant 4 A patient who is on a normal diet after an abdominal surgery 5 An older adult patient who has had cardiac surgery, but who is performing a normal physical activity

1 A patient who has urinary incontinence 2 A patient who has had hip replacement surgery 3 A patient who walks with the help of an assistant

What purpose does the dry gauze dressing serve in wound healing? Select all that apply. 1 Aids in hemostasis 2 Keeps the wound dry 3 Provides debridement 4 Keeps the periwound skin moist 5 Prevents microbial contamination

1 Aids in hemostasis 3 Provides debridement 5 Prevents microbial contamination

What are the advantages of using hydrogel dressing? Select all that apply. 1 Allows for easy removal 2 Minimizes skin trauma 3 Debrides necrotic tissue 4 Permits viewing of wound 5 Provides a moist environment

1 Allows for easy removal 3 Debrides necrotic tissue 5 Provides a moist environment

Which task can be delegated to nursing assistive personnel (NAP) in caring for a patient who has pressure ulcers? 1 Applying an elastic bandage 2 Performing wound irrigation 3 Implementing negative-pressure wound therapy 4 Assessing the patient for the risk of additional pressure ulcers

1 Applying an elastic bandage

Which nursing actions are appropriate when providing care to a patient who is diagnosed with a stage III, IV, or unstageable pressure ulcer? Select all that apply. 1 Avoid prolonged elevation of the head of the bed 2 Consider the use of a wheelchair cushion 3 Order a standard hospital foam mattress 4 Consider an alternating pressure support surface 5 Place a pillow under the calves to decrease the risk of heel breakdown

1 Avoid prolonged elevation of the head of the bed 2 Consider the use of a wheelchair cushion 4 Consider an alternating pressure support surface 5 Place a pillow under the calves to decrease the risk of heel breakdown

The nurse observes increased wound drainage in a patient provided with a moist-to-dry dressing for pressure ulcers. What should be the immediate nursing intervention? 1 Change the dressing 2 Obtain wound culture 3 Apply pressure on the wound 4 Monitor the patient's white blood cell count

1 Change the dressing

A patient provided with polyurethane foam for negative-pressure wound therapy (NPWT) complains of severe pain. Which intervention would be most appropriate to manage the patient's condition in this situation? 1 Change the wound filler 2 Change the brand of NPWT unit 3 Obtain wound cultures prior to dressing change 4 Avoid placing of drainage tubing over bony prominences

1 Change the wound filler

The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indicates a need for further learning? 1 Choosing a dressing that keeps the periwound moist 2 Applying a dressing that controls exudates from the wound 3 Cleaning the periwound and wound without applying pressure 4 Using sterile normal saline and a sterile gauze to clean the surgical wound

1 Choosing a dressing that keeps the periwound moist

What are the functions of black polyurethane foam in wound healing? Select all that apply. 1 Contracts the wound 2 Absorbs fluids from the wound 3 Restricts the growth of granulation tissue 4 Helps to determine depth of the wound 5 Protects the periwound tissue from pressure

1 Contracts the wound 2 Absorbs fluids from the wound

During assessment, the nurse notes a foul-smelling drainage from the wound with deep tunneling. Which actions of the nurse indicate the need for further teaching? Select all that apply. 1 Covering the entire wound with the gauze 2 Placing the dripping wet gauze into the tunnel 3 Using the gauze only to clean the wound 4 Using the Montgomery ties to secure the dressing 5 Using dry dressing and topper dressing over inner gauze

1 Covering the entire wound with the gauze 2 Placing the dripping wet gauze into the tunnel

What intervention is not necessary for a patient who has impaired skin integrity related to limited mobility? 1 Demonstrate correct repositioning techniques. 2 Apply dressings to support moist wound healing. 3 Perform an ongoing wound and risk assessment. 4 Apply a moisture barrier to the area at least three times daily.

1 Demonstrate correct repositioning techniques.

Which condition warrants the use of cold therapy? 1 Direct trauma 2 Rectal surgery 3 Painful hemorrhoids 4 Vaginal inflammation

1 Direct trauma

What is the advantage of a moist application in wound healing? 1 Does not promote sweating 2 Does not cause skin maceration 3 Retains temperature longer 4 Less risk for burns to the skin than dry applications

1 Does not promote sweating

A 76-year-old female patient who has osteoarthritis and mild hypertension develops redness and oozing of foul-smelling tan-colored drainage from her hip incision on postoperative day 4. Because of the pain at the incision site, she needs assistance in turning and transferring herself from her bed to the chair. What intervention will the nurse avoid? 1 Elevating the head of the bed to 45 degrees 2 Irrigating the wound with saline solution twice a day 3 Helping the patient with repositioning every 90 minutes 4 Checking the patient's pain level and offering analgesics at frequent intervals

1 Elevating the head of the bed to 45 degrees

While caring for a patient who has a chronic wound, the nurse observes exudates in the periwound area. Which nursing intervention is appropriate in this scenario? Select all that apply. 1 Increase the frequency of dressing change 2 Use of sterile cotton-tipped applicator 3 Use of petrolatum-based skin protectant 4 Use of Dakin's solution for cleaning the wound 5 Use of dressing material that has more absorbing capacity

1 Increase the frequency of dressing change 3 Use of petrolatum-based skin protectant 5 Use of dressing material that has more absorbing capacity

What step is a component of the planning phase for a patient who has impaired skin integrity? 1 Involve the patient and family in choosing interventions. 2 Apply standards of practice outlining expected outcomes. 3 Examine the patient's skin for impairment of skin integrity. 4 Ask the patient for his or her perception of skin integrity after the intervention.

1 Involve the patient and family in choosing interventions.

Which nursing actions are appropriate when removing tape from the patient's skin during wound care? Select all that apply. 1 Loosen the ends 2 Pull the tape in the direction of hair growth 3 Use adhesive remover to loosen the tape 4 Apply hard traction to the skin next to the wound 5 Gently pull the outer end perpendicular to the skin surface

1 Loosen the ends 2 Pull the tape in the direction of hair growth 3 Use adhesive remover to loosen the tape

A patient developed a pressure ulcer after knee surgery due to restriction to bed. Which irrigating fluid should the nurse use to clean the ulcer? 1 Normal saline 2 Povidone iodine 3 Hydrogen peroxide 4 Sodium hypochlorite

1 Normal saline

The nurse performs the skin and risk assessment on a patient who has diabetes and limited mobility due to a fractured left hip and finds that the skin is intact without any skin disintegration. Which nursing intervention should the nurse provide to the patient? 1 Place a pillow under the patient's calves. 2 Position the patient at a 30-degree medial turn. 3 Use standard hospital foam mattresses for the patient. 4 Recommend alternating pressure support surfaces for the patient

1 Place a pillow under the patient's calves.

The nurse determines the patient's risk of developing ulcers using the Braden Scale and finds the score to be 16. Which nursing interventions are appropriate for the patient to decrease the risk of skin breakdown? Select all that apply. 1 Protecting the patient's heels 2 Turning the patient frequently 3 Providing pressure-redistribution surfaces 4 Providing foam-wedges for 40-degree lateral position 5 Applying a moisturizer to the patient's wound regularly

1 Protecting the patient's heels 2 Turning the patient frequently 3 Providing pressure-redistribution surfaces

After receiving negative suction wound therapy for pressure ulcers, the patient complains of severe pain. What should be the immediate nursing action? 1 Reduce the suction 2 Notify the health care provider 3 Increase frequency of dressing change 4 Reinforce with transparent dressing strips

1 Reduce the suction

What is the most important nursing intervention that the nurse should provide to a patient who has impaired physical mobility related to incisional pain? 1 Reposition the patient at least once every 90 minutes. 2 Apply a dressing to the area to support moist wound healing. 3 Apply a moisture barrier to the incisional area at least three times daily. 4 Pack open areas of the wound with gauze moistened with antibiotic solution

1 Reposition the patient at least once every 90 minutes.

Which intervention is part of the nursing intervention classification (NIC) for pressure management care? 1 Repositioning the patient every 90 minutes 2 Irrigating the wound with a saline solution two times per day 3 Avoiding the use of massage around the open area 4 Elevating the head of the patient's bed to no more than 30 degrees

1 Repositioning the patient every 90 minutes 3 Avoiding the use of massage around the open area 4 Elevating the head of the patient's bed to no more than 30 degrees

Which interventions are part of the nursing intervention classification (NIC) of pressure management? Select all that apply. 1 Repositioning the patient every 90 minutes 2 Irrigating the wound with a saline solution two times per day 3 Avoiding the use of massage around the open area 4 Dressing the area two times per day per provider prescription 5 `Elevating the head of the patient's bed to no more than 30 degrees

1 Repositioning the patient every 90 minutes 3 Avoiding the use of massage around the open area 5 `Elevating the head of the patient's bed to no more than 30 degrees

Which nursing interventions minimize the risk for pressure ulcer development? Select all that apply. 1 Repositioning the patient every two hours 2 Using a draw sheet to assist with repositioning 3 Conducting a nutritional assessment every 8 hours 4 Applying barrier creams for patients who are incontinent 5 Providing education related to preventing skin breakdown

1 Repositioning the patient every two hours 2 Using a draw sheet to assist with repositioning 4 Applying barrier creams for patients who are incontinent 5 Providing education related to preventing skin breakdown

Identify the type of suture depicted in the image. 1 Retention 2 Continuous 3 Intermittent 4 Blanket continuous

1 Retention

Upon assessing a patient's surgical incision on the left hip, the nurse observes reddened periwound tissue, foul drainage, and open areas between the staples. What is the likely nursing diagnosis? 1 Risk for infection 2 Risk for inflammation 3 Impaired skin integrity related to limited mobility 4 Impaired physical mobility related to incisional pain

1 Risk for infection

The registered nurse is teaching a nursing student about the instructions to be followed while dressing any type of wound. Which statement made by the nurse indicates effective learning? Select all that apply. 1 Select the dressing that controls the exudate 2 Choose the dressing that keeps the periwound area moist 3 Use the same type of dressing throughout the wound care 4 Use the dressing that provides a moist environment to the ulcer bed 5 Clean the wound and periwound area while dressing for the first time

1 Select the dressing that controls the exudate 4 Use the dressing that provides a moist environment to the ulcer bed

Which type of wound drainage is shown in the image on the next slide? 1 Serous 2 Purulent 3 Sanguineous 4 Serosanguineous

1 Serous

Which type of ulcer can be dressed with a transparent or hydrocolloid dressing? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

1 Stage I

While treating a patient with negative-pressure wound therapy (NWPT) for radiation-damaged skin on the forearm, the nurse observes pressure ulcers on the elbow. Which nursing action is responsible for the patient's condition? 1 The nurse placed the tubing over the elbow. 2 The nurse removed the transparent film by stretching it horizontally. 3 The nurse raised the tubing connectors above the level of the NWPT unit. 4 The nurse kept the system in "de vac" mode for 30 minutes before changing the dressing

1 The nurse placed the tubing over the elbow.

Which statement is true regarding hydrogel dressings? 1 They enhance autolytic debridement. 2 They may not require secondary dressing. 3 They are not used to relieve pain in the wounds. 4 They are sheet dressings impregnated with saline solution

1 They enhance autolytic debridement.

Which statement is true regarding hydrogel dressings? 1 They enhance autolytic debridement. 2 They may not require secondary dressing. 3 They are not used to relieve pain in the wounds. 4 They are sheet dressings impregnated with saline solution.

1 They enhance autolytic debridement.

Which factor increases the risk for injury when applying heat therapy to a wound for a pediatric patient? 1 Thinner layers of skin 2 Alteration in nerve pathways 3 Rupture and systemic infection 4 Decreased peripheral circulation

1 Thinner layers of skin

Which can cause an acute wound? Select all that apply. 1 Trauma 2 Pressure 3 Surgical incision 4 Vascular compromise 5 Repetitive insults to tissue

1 Trauma 3 Surgical incision

Which nursing action is appropriate when providing care to a patient who exhibits no risk for skin breakdown? 1 Using a standard surface 2 Using a pillow under the calves 3 Using an active support surface 4 Using a pressure-redistribution seat cushion

1 Using a standard surface

Which topical solutions can be used to clean a granulating wound? Select all that apply. 1 Water 2 Acetic acid 3 Normal saline 4 Hydrogen peroxide 5 Sodium hypochlorite

1 Water 3 Normal saline

The nurse observes that a patient's ulcer is very slow to heal. Which action made by the nurse can help facilitate faster healing of the patient's wound? 1 Obtaining necessary wound cultures 2 Assessing the ulcer during each dressing 3 Using liquid skin barrier on periwound skin 4 Irrigating the wound with topical agents frequently

2 Assessing the ulcer during each dressing

Arrange in order the steps that the nurse follows while treating pressure ulcers in a patient. 1. Remove the dressing and place it in a plastic bag 2. Position the patient for access to dressing removal 3. Measure the length and width of the pressure ulcer 4. Determine if the patient has allergies to topical agents 5. Determine if the patient needs pain medication

1. Determine if the patient has allergies to topical agents 2. Determine if the patient needs pain medication 3. Position the patient for access to dressing removal 4. Remove the dressing and place it in a plastic bag 5. Measure the length and width of the pressure ulcer

Arrange the steps for preparing an ice bag in order. 1. Squeeze the bag's sides to release any air. 2. Fill the bag with water, and check it for leaks. 3. Cover the bag with a flannel cover, towel, or pillowcase. 4. Fill two thirds of the bag with crushed ice.

1. Fill the bag with water, and check it for leaks. 2. Fill two thirds of the bag with crushed ice. 3. Squeeze the bag's sides to release any air. 4. Cover the bag with a flannel cover, towel, or pillowcase.

Arrange the events that occur during the proliferative phase of wound healing in chronological order. 1. Contraction of the wound 2. Synthesis of collagen from fibroblasts 3. Migration of the epithelial cells from the wound edges 4. Mixing of collagen with granulation tissue

1. Synthesis of collagen from fibroblasts 2. Mixing of collagen with granulation tissue 3. Contraction of the wound 4. Migration of the epithelial cells from the wound edges

When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary unless the patient's last shot was administered within the past _____ years. Record you answer using whole number.

10 years

What quantity of vitamin C is recommended for wound healing? Record your answer using a whole number. ______ mg/day

1000mg

Which patient statement indicates understanding of the disadvantages of using moist applications for wound therapy? 1 "It increases body fluid loss." 2 "It causes maceration of the skin." 3 "It causes increased drying of the skin." 4 "It does not penetrate deep into tissues.

2 "It causes maceration of the skin."

A nursing instructor discusses with a nursing student the changes that occur in the skin with aging. Which of the student's statements indicates the need for further teaching? 1 " The elasticity of the skin decreases with age." 2 "The collagen content of the skin increases with age." 3 "The underlying muscle and tissues become thinner with age." 4 "The older adult's skin can be easily torn in response to mechanical trauma."

2 "The collagen content of the skin increases with age."

Which topical agents are used to clean highly colonized wounds? Select all that apply. 1 Water 2 Acetic acid 3 Saline solution 4 Hydrogen peroxide 5 Sodium hypochlorite

2 Acetic acid 4 Hydrogen peroxide 5 Sodium hypochlorite

The nurse is providing care to a patient with a pressure ulcer that is covered in eschar. Which dressing prescription will the nurse use for this patient? 1 None 2 Adherent film 3 Composite film 4 Calcium alginate

2 Adherent film

The health care provider instructs the nurse to change the dressing of a patient's wound. While carrying out the order, the nurse observes bleeding in the wound region. Which nursing interventions are appropriate to manage the patient's condition? Select all that apply. 1 Obtain the wound culture 2 Apply pressure on the wound 3 Assess the vital signs of the patient 4 Cover the wound site with sterile moist dressing 5 Determine the amount of bleeding underneath the patient

2 Apply pressure on the wound 3 Assess the vital signs of the patient 5 Determine the amount of bleeding underneath the patient

Which nursing actions are appropriate for cleaning the area surrounding a drain site? Select all that apply. 1 Reuse gauze to clean across the site 2 Clean from the drain site to the surrounding skin 3 Use hard friction when applying solutions locally to the skin 4 After applying a solution to sterile gauze, clean away from the wound 5 Allow irrigating solution to flow from the least to most contaminated area

2 Clean from the drain site to the surrounding skin 4 After applying a solution to sterile gauze, clean away from the wound 5 Allow irrigating solution to flow from the least to most contaminated area

Which nursing actions are intended to minimize patient pain when performing a wound care procedure? Select all that apply. 1 Clipping any hair around the patient's wound 2 Cleaning the patient's wound edges gently 3 Turning and repositioning the patient carefully 4 Administering prescribed analgesics as ordered 5 Removing tape from the patient's skin with force

2 Cleaning the patient's wound edges gently 3 Turning and repositioning the patient carefully 4 Administering prescribed analgesics as ordered

Which advantages should the nurse include in a teaching session on using dry applications when treating a wound? Select all that apply. 1 Softens wound exudate 2 Decreases the risk for burns 3 Conforms well to most body areas 4 Penetrates deeply into tissue layers 5 Retains temperature longer because evaporation does not occur

2 Decreases the risk for burns 5 Retains temperature longer because evaporation does not occur

A patient who has a stage III pressure ulcer develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. What will the nurse suspect is occurring in the patient? 1 Bruising 2 Infection 3 Internal bleeding 4 Blanchable erythema

2 Infection

A patient with limited mobility develops a sacral pressure ulcer. Which nursing interventions are appropriate for reducing the risk for infection? Select all that apply. 1 Obtaining a wound culture as needed 2 Irrigating and cleansing the wound with saline twice a day 3 Repositioning the patient at least every 90 minutes 4 Packing the open wound with antibiotic solution-moistened gauze

2 Irrigating and cleansing the wound with saline twice a day 4 Packing the open wound with antibiotic solution-moistened gauze

Which intervention is part of the nursing intervention classification (NIC) for wound care? 1 Repositioning the patient every 90 minutes 2 Irrigating the wound with a saline solution two times per day 3 Avoiding the use of massage around the open area 4 Elevating the head of the patient's bed to no more than 30 degrees

2 Irrigating the wound with a saline solution two times per day

Which interventions are part of the nursing intervention classification (NIC) of wound care? Select all that apply. 1 Repositioning the patient every 90 minutes 2 Irrigating the wound with a saline solution two times per day 3 Avoiding the use of massage around the open area 4 Dressing the area two times per day per provider prescription 5 `Elevating the head of the patient's bed to no more than 30 degrees

2 Irrigating the wound with a saline solution two times per day 4 Dressing the area two times per day per provider prescription

Which pressure ulcer site is found immediately distal to the buttock? 1 Sole 2 Ischium 3 Sacrum 4 Scapula

2 Ischium

A patient is diagnosed with moderate deep dermal ulcers. Why would the nurse provide a hydrocolloid dressing to this patient? Select all that apply. 1 Reduces wound pain 2 Minimizes skin trauma 3 Permits viewing a wound 4 Provides moist environment 5 Slowly liquefies necrotic debris

2 Minimizes skin trauma 4 Provides moist environment 5 Slowly liquefies necrotic debris

Which nursing intervention is appropriate for a patient who is at risk for infection due to a surgical incision at the right hip? 1 Applying moisture barrier cream 2 Obtaining a wound culture as needed 3 Providing analgesics prior to wound care 4 Using correct repositioning techniques

2 Obtaining a wound culture as needed

The nurse notes a quarter-sized area of blanchable erythema over the patient's sacral area. The nurse knows this finding is likely due to what? 1 Friction 2 Pressure 3 Massage 4 Sheering force

2 Pressure

Which can cause a chronic wound? Select all that apply. 1 Trauma 2 Pressure 3 Surgical incision 4 Vascular compromise 5 Repetitive insults to tissue

2 Pressure 4 Vascular compromise 5 Repetitive insults to tissue

A patient's wound drainage appears thick and yellow. Which type of drainage is this considered? 1 Serous 2 Purulent 3 Sanguineous 4 Serosanguineous

2 Purulent

Which type of wound drainage is shown in the image on the next slide? 1 Serous 2 Purulent 3 Sanguineous 4 Serosanguineous

2 Purulent

While caring for a patient who has pressure ulcers, the nurse finds that the skin surrounding the ulcer has become macerated. Which nursing intervention would be most appropriate to manage the patient's condition? Select all that apply. 1 Obtaining necessary wound cultures 2 Reporting to the primary health care provider 3 Applying liquid skin barrier on the periwound skin 4 Changing the analgesic used for curing the wound 5 Reducing the exposure of wound to topical agents

2 Reporting to the primary health care provider 3 Applying liquid skin barrier on the periwound skin 5 Reducing the exposure of wound to topical agents

What is characteristic of stage III pressure ulcers? 1 Underlying muscle is exposed 2 Slough may be present with slough, but it does not obscure the depth of tissue loss. 3 Discoloration of the skin, warmth, edema, hardness, and/or pain may be present. 4 It presents as a shallow, open ulcer with a red-pink wound bed without slough.

2 Slough may be present, but it does not obscure the depth of tissue loss.

Which stage of the pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

2 Stage II

How is the nursing care for a patient who has a stage IV pressure ulcer different from that for a patient who has a stage I pressure ulcer? 1 Stage IV requires keeping the patient out of a have slouched position. 2 Stage IV requires the use of a low-air-loss, alternating pressure, or air-fluidized support surface. 3 Stage IV requires keeping the patient out of a prolonged head-of-bed elevation position. 4 Stage IV requires consulting a seating specialist for the appropriate seating surface for the patient.

2 Stage IV requires the use of a low-air-loss, alternating pressure, or air-fluidized support surface.

Which statement regarding the skin is true? 1 The stratum corneum prevents entrance of topical medications. 2 The dermis and the inner layer of the skin provide tensile strength. 3 The basal layer of the epidermis is responsible for collagen formation. 4 The three layers of the skin are the epidermis, dermis, and endodermis

2 The dermis and the inner layer of the skin provide tensile strength.

While caring for a patient who had hip replacement surgery and developed pressure ulcers, the nurse applies debriding enzymes on the ulcer region. After few hours, the patient complains of burning sensation in the wound area. Which nursing action is responsible for the patient's condition? 1 The nurse applied foam directly over the ulcer. 2 The nurse applied ointment to the surrounding skin. 3 The nurse applied gauze dressing directly over the ulcer. 4 The nurse applied a thin ointment layer over the necrotic area of ulcer

2 The nurse applied ointment to the surrounding skin.

What does the nonblanchable erythema indicate about the skin? 1 The tissue is infected. 2 The tissue is damaged. 3 The tissue is under hypoxia. 4 The tissue is under pressure.

2 The tissue is damaged.

What does the nonblanchable erythema indicate about the skin? 1 The tissue is infected. 2 The tissue is damaged. 3 The tissue is under hypoxia. 4 The tissue is under pressure.

2 The tissue is damaged..

The nurse is assisting the primary health care provider in applying moist dressing for a patient who has pressure ulcers. The nurse reviews the orders for the dressing change procedure. What is the rationale behind this nursing action? 1 To prevent adverse reactions 2 To learn the type of dressing that is to be used 3 To determine the specific areas that will be included during patient teaching 4 To plan for the proper type of supplies required for dressing

2 To learn the type of dressing that is to be used

A patient with an abdominal wound from a motor vehicle accident comes into the emergency room with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. What is the rationale for this nursing action? 1 To reduce pain 2 To prevent infection 3 To prevent pressure ulcers 4 To prevent periwound edema

2 To prevent infection

What is the rationale behind cleaning the wound with normal saline using an irrigating syringe? 1 To reduce the pain 2 To remove wound debris 3 To provide a moist environment to the wound 4 To reduce the transmission of microorganisms

2 To remove wound debris

What should the nurse consider when developing a nursing plan for an immobile patient whose skin is intact but is at a high risk for impaired skin integrity? Select all that apply. 1 Consider either a low-air-loss, alternating pressure, or air-fluidized support surface. 2 Use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown. 3 Consider the use of a wheelchair cushion. 4 Use an active support surface, such as an overlay or mattress, when frequent manual repositioning is difficult. 5 Avoid prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx.

2 Use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown. 4 Use an active support surface, such as an overlay or mattress, when frequent manual repositioning is difficult. 5 Avoid prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx.

Which nursing actions will help maintain an airtight seal for a patient who is prescribed negative-pressure wound therapy? Select all that apply. 1 Retaining hair around the wound 2 Using s skin barrier around the wound 3 Drying around the wound thoroughly 4 Applying adhesive remover to the wound edges 5 Filling uneven wound surfaces with a hydrocolloid product

2 Using s skin barrier around the wound 3 Drying around the wound thoroughly 5 Filling uneven wound surfaces with a hydrocolloid product

Which nutrient supports healing by promoting wound closure? 1 Protein 2 Vitamin A 3 Vitamin C 4 Zinc

2 Vitamin A

Which nutrient supports healing by promoting wound closure? 1 Protein 2 Vitamin A 3 Vitamin C 4 Zinc

2 Vitamin C

Arrange the steps for preparing an ice bag in order. 1. Squeeze the bag's sides to release any air. 2. Fill the bag with water, and check it for leaks. 3. Cover the bag with a flannel cover, towel, or pillowcase. 4. Fill two thirds of the bag with crushed ice.

2. Fill the bag with water, and check it for leaks. 1. Fill two thirds of the bag with crushed ice. 3. Squeeze the bag's sides to release any air. 4. Cover the bag with a flannel cover, towel, or pillowcase

A nurse is educating a patient about the role of nutrients in wound healing. Which statement will the nurse include? 1 "Zinc facilitates angiogenesis, and the recommended quantity is 10 to 15 mg." 2 "Vitamin C promotes collagen synthesis, and the recommended quantity is 2000 mg/day." 3 "Protein facilitates collagen formation, and the recommended quantity is 1.25 to 1.5 g protein per kilogram of body weight." 4 "Vitamin A promotes wound closure, and the recommended quantity is 1100 to 1400 retinol equivalents per day."

3 "Protein facilitates collagen formation, and the recommended quantity is 1.25 to 1.5 g protein per kilogram of body weight."

Which equipment should the nurse have available when irrigating a surgical wound? 1 A catheter tip 20-mL syringe 2 A catheter tip 60-mL syringe 3 A 35-mL syringe with a 19-gauge soft angiocatheter 4 A 20-mL syringe with a 17-gauge soft angiocatheter

3 A 35-mL syringe with a 19-gauge soft angiocatheter

Which factor does not put a patient at risk for burns during heat therapy? 1 Very young age 2 Areas of edema 3 Abscessed tooth 4 Peripheral vascular disease

3 Abscessed tooth

Under the supervision of the registered nurse, a nursing student is providing negative-pressure wound therapy to a patient who has a wound near the knee joint. Which nursing action indicates the need for further learning? 1 Drying the periwound thoroughly before dressing 2 Covering the skin near the suction line with at hydrocolloid dressing 3 Applying adhesive remover at the affected site before the dressing 4 Dressing the wound with a hydrocolloid film 3 cm away from the wound

3 Applying adhesive remover at the affected site before the dressing

The nurse reviews the primary health care provider's orders for the amount of negative pressure to be applied while providing negative-pressure wound therapy (NPWT) to a patient. Which step of the nursing process is involved in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

3 Assessment

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated? 1 Pallor or molting 2 Dark red or purple discoloration 3 Blanchable erythema 4 Nonblanchable erythema

3 Blanchable erythema

Upon observation the nurse sees the leakage of serous fluid from a patient's ulcer dressing. Which type of topical agents should the nurse use in this situation? 1 Hydrogel 2 Normal saline 3 Calcium alginate 4 Debriding enzymes

3 Calcium alginate

The registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning? 1 Cleaning a wound with normal saline 2 Using a different method of specimen collection for each type of organism 3 Collecting wound culture samples from old drainage 4 Using a 10-mL disposable syringe with a 22-gauge needle

3 Collecting wound culture samples from old drainage

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to poor dietary intake? 1 Keep the skin dry and free of maceration 2 Provide pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed

3 Consult a dietician for nutritional assessment

Which is characteristic of abnormal healing in a primary-intention wound? 1 Pale and fragile granulation tissue 2 Necrotic or slough tissue present in the wound base 3 Drainage present more than three days after closure 4 Presence of fistula, tunneling, undermining, and/or a fruity odor

3 Drainage present more than three days after closure

Under the supervision of the registered nurse, the nursing student is repositioning a patient to reduce the risk of pressure ulcers. Which nursing action indicates a need for further learning? 1 Teaching the patient to shift his or her weight every 15 minutes 2 Encouraging the patient to sleep in a supine position 3 Encouraging the patient to sit on a donut-shaped cushion 4 Encouraging the patient to place the ischial areas on an air-filled pillow

3 Encouraging the patient to sit on a donut-shaped cushion

Which nursing interventions are appropriate for a patient who is at risk for pressure ulcer development due to impaired mobility or friction and shear? Select all that apply. 1 Assisting with meals 2 Applying a moisture barrier cream 3 Establishing a schedule for repositioning 4 Limiting head elevation to 30 degrees 5 Repositioning with a transfer board surface

3 Establishing a schedule for repositioning 4 Limiting head elevation to 30 degrees 5 Repositioning with a transfer board surface

Which nursing action is appropriate when framing the periwound area with skin sealant? 1 Extending the sealant 1 to 2 cm (0.4 to 0.8 in) beyond the wound edges 2 Extending the sealant 2 to 4 cm (0.8 to 1.6 in) beyond the wound edges 3 Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges 4 Extending the sealant 4 to 6 cm (1.6 to 2.4 in) beyond the wound edges

3 Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges

Which fluids if exposed to the skin pose the highest risk for skin breakdown? 1 Ascitic fluids 2 Biliary secretions 3 Gastric secretions 4 Purulent wound exudates

3 Gastric secretions

A patient developed a pressure ulcer that was deep with the presence of exudates. Which type of dressing is provided to the patient? 1 Film 2 Foam 3 Hydrogel 4 Calcium alginate

3 Hydrogel

Which statement is true regarding cold application? 1 It causes vasodilation. 2 It reduces blood viscosity. 3 It decreases muscle tension. 4 It increases tissue metabolism.

3 It decreases muscle tension.

Which statement is true regarding nonblanchable erythema? 1 It occurs due to tissue hypoxia. 2 It is an early indication of pressure. 3 It indicates potential damage to blood vessels. 4 It turns white under the application of pressure

3 It indicates potential damage to blood vessels.

The nurse is caring for a patient who is diagnosed with venous stasis ulcers. Which support surface should the nurse anticipate for this patient? 1 Low-air-loss bed 2 Nonpowered bed 3 Lateral rotation 4 Air-fluidized bed

3 Lateral rotation

Which type of support surface should the nurse plan to use to treat and prevent pulmonary, venous stasis, and urinary complications associated with immobility? 1 Low-air-loss 2 Nonpowered 3 Lateral rotation 4 Air-fluidized beds

3 Lateral rotation

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility? 1 Low-air-loss surface 2 Nonpoweredsurface 3 Lateral rotation surface 4 Air-fluidized bed

3 Lateral rotation surface

Which blood cells are known as garbage cells? 1 Neutrophils 2 Erythrocytes 3 Macrophages 4 T-lymphocytes

3 Macrophages

Which equipment is used by the primary health care provider while applying moist dressing to a patient who has pressure ulcers? 1 Linen bag 2 Braden scale 3 Montgomery ties 4 Waterproof underpad

3 Montgomery ties

Which nursing interventions are appropriate when a patient complains of sensation under the dressing? Select all that apply. 1 Apply pressure over the wound 2 Instruct the patient to walk for some time 3 Observe the wound for increased drainage 4 Report to the primary health care provider immediately 5 Cover the wound with a sterile moist dressing if underlying organs protrude

3 Observe the wound for increased drainage 4 Report to the primary health care provider immediately 5 Cover the wound with a sterile moist dressing if underlying organs protrude

According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer? 1 Dry skin 2 Walks occasionally 3 Poor nutrition 4 Slightly limited sensory perception

3 Poor nutrition

What is the role of vitamin A in wound healing? 1 Quickens fibroplasia 2 Acts as an antioxidant 3 Promotes wound closure 4 Encourages collagen formation

3 Promotes wound closure

What action will the nurse take while removing a dressing on an older adult patient? 1 Pull the skin from the adhesive 2 Pull the adhesive from the skin 3 Push the skin away from the adhesive 4 Push the adhesive away from the skin

3 Push the skin away from the adhesive

Which type of wound drainage is shown in the image on the next slide? 1 Serous 2 Purulent 3 Sanguineous 4 Serosanguineous

3 Sanguineous

For which pressure ulcers would the nurse include education related to both granulation and reepithelialization? Select all that apply. 1 Stage I 2 Stage II 3 Stage III 4 Stage IV 5 Unstageable

3 Stage III 4 Stage IV

Which pressure ulcer is expected to heal through granulation and reepithelialization? 1 Stage I 2 Stage II 3 Stage IV 4 Unstageable

3 Stage IV

Which adjuvant treatments are only considered for patients diagnosed with clean stage IV or unstageable pressure ulcers? Select all that apply. 1 Support hydration 2 Nutritional support 3 Surgical consultation for closure 4 Surgical consultation for debridement 5 Evaluation of pressure-redistribution needs

3 Surgical consultation for closure 4 Surgical consultation for debridement

Which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure ulceration? 1 Support hydration 2 Nutritional support 3 Surgical consultation for debridement 4 Evaluation of pressure-redistribution needs

3 Surgical consultation for debridement

The nurse uses an elastic net as additional dressing in a patient's leg region. What is the rationale behind this nursing action? 1 To improve patient comfort 2 To determine the rate of healing 3 To prevent the dressing from slipping 4 To reduce transmission of infection to other parts of the body

3 To prevent the dressing from slipping

Which dressing is inappropriate for a patient with a clean stage II pressure ulcer? 1 Gauze 2 Hydrogel 3 Transparent 4 Hydrocolloid

3 Transparent

The absence of adequate amounts of which nutrient in the diet may impair inflammatory response in wound healing? 1 Zinc 2 Proteins 3 Vitamin A 4 Vitamin C

3 Vitamin A

Which nutrient is an antioxidant that promotes wound healing? 1 Zinc 2 Protein 3 Vitamin C 4 Vitamin A

3 Vitamin C

A nurse discusses the purposes of wound dressings with a nursing student. Which of the nursing student's statements indicates the need for further learning? 1 "Dressings absorb drainage to promote wound healing." 2 "Dressings promote hemostasis and thermal insulation." 3 "Dressings help reduce exposure to microorganisms, and they support the wound site." 4 "Dressings provide a dry environment to facilitate healing."

4 "Dressings provide a dry environment to facilitate healing."

The registered nurse is providing dietary instructions to a patient who has pressure ulcers. Which statements by the nurse are true? Select all that apply. 1 "You should avoid eating sweet potatoes every day." 2 "You should eat nearly 500 mg of citrus fruits daily." 3 "You should drink nonalcoholic fluids such as soda daily." 4 "You should consume 1.25 g of protein per kg body weight each day." 5 "You should avoid eating foods that contain high amounts of zinc."

4 "You should consume 1.25 g of protein per kg body weight each day." 5 "You should avoid eating foods that contain high amounts of zinc."

What amount of retinol equivalents for vitamin A per day should the nurse recommend a patient to consume to support proper wound healing? 1 1200-1400 2 1400-1500 3 1500-1600 4 1600-2000

4 1600-2000

How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing? 1 15-20 kcal 2 20-25 kcal 3 25-30 kcal 4 30-35 kcal

4 30-35 kcal

What amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing? 1 15-20 mL 2 20-25 mL 3 25-30 mL 4 30-35 mL

4 30-35 mL

When performing any wound care procedure, which nursing action is appropriate for addressing the patient's pain and discomfort? 1 Administering pain medication after the procedure 2 Administering pain medication at the beginning of the procedure 3 Administering pain medication 10 to 20 minutes before the procedure 4 Administering pain medication 30 to 60 minutes before the procedure

4 Administering pain medication 30 to 60 minutes before the procedure

The nurse is preparing a care plan for a patient who has a pressure ulcer on the coccyx. Which part of the plan is included to provide comfort to the patient? 1 Repositioning the patient every 90 minutes 2 Cleaning and massaging around the affected area 3 Elevating the head of the patient's bed to 30 degrees 4 Applying a moisture barrier ointment over the ulcer

4 Applying a moisture barrier ointment over the ulcer

A patient who has an acute wound due to trauma is admitted to the emergency unit. Which nursing action for wound care is the priority in this situation? 1 Educating the patient about wound care 2 Positioning the patient in different angles 3 Encouraging the patient to drink 6 to 8 L of water 4 Applying a sterile dressing as per the health care provider's order

4 Applying a sterile dressing as per the health care provider's order

Which nursing action during removing tape from the patient's skin during wound care requires correction? 1 Loosening the ends 2 Pulling the tape in the direction of hair growth 3 Using adhesive remover to loosen the tape 4 Applying hard traction to the skin next to the wound

4 Applying hard traction to the skin next to the wound

Which dressing will the nurse use for a patient with a clean stage III pressure ulcer? 1 None 2 Adherent film 3 Composite film 4 Calcium alginate

4 Calcium alginate

When cleaning a wound, which action is incorrect? 1 Using two separate swabs to clean the affected site 2 Irrigating from the least to most contaminated area 3 Applying noncytotoxic solutions using gentle friction 4 Cleaning from the surrounding skin to the site of incision

4 Cleaning from the surrounding skin to the site of incision

Which action is involved in safely removing retention sutures? 1 Cut the suture at the end nearest to the knot. 2 Cut the suture as farthest to the skin edge as possible. 3 Pull the visible part of the suture above the skin through underlying tissue. 4 Clip suture materials nearest to the skin edge on one side, and pull from the other side.

4 Clip suture materials nearest to the skin edge on one side, and pull from the other side.

Which is characteristic of abnormal healing of a primary wound? 1 Slough tissue in the wound base 2 A fruity, earthy, or putrid odor 3 A dry or moist granulation tissue bed 4 Drainage for more than 3 days after closure

4 Drainage for more than 3 days after closure

Which piece of knowledge does a nurse not require for assessing a patient's risk for developing pressure ulcers? 1 Pathogenesis of pressure ulcers 2 Factors contributing to pressure ulcer formation 3 Factors contributing to wound healing 4 Factors contributing to inflammation and infection

4 Factors contributing to inflammation and infection

Which dressing should the nurse use to protect and absorb moisture when providing care to a patient with a pressure ulcer? 1 Gauze 2 Adherent film 3 Calcium alginate 4 Hydrogel covered with foam

4 Hydrogel covered with foam

In a supine position, which site is not at risk for a pressure ulcer? 1 Ischium 2 Elbow 3 Occipital bone 4 Medial knee

4 Medial knee

The nurse observes the development of a pressure ulcer in a patient while providing care after hip replacement surgery. Which nursing intervention would have prevented the pressure ulcer? 1 Assessing sensory perception 2 Using foam wedges for positioning 3 Frequently turning the patient on the bed 4 Monitoring the surgical area for drainage

4 Monitoring the surgical area for drainage

What intervention should the nurse plan for a patient who has a sacral pressure ulcer? 1 Apply a moisture barrier to the wound at least twice daily. 2 Administer an analgesic 15 minutes before repositioning and wound care. 3 When the patient is lying down, position him or her in a 45-degree lateral position. 4 Pack open areas of the wound with gauze moistened with an antibiotic solution

4 Pack open areas of the wound with gauze moistened with an antibiotic solution

Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels? 1 Avoid prolonged elevation of the head of the bed 2 Order a standard hospital foam mattress 3 Consider an alternating pressure support surface 4 Place a pillow under the calves

4 Place a pillow under the calves

Which is characteristic of abnormal healing in a secondary-intention wound? 1 Increase in inflammation in the first 3 to 5 days after injury 2 Absence of epithelialization of wound edges by day 4 3 Presence of drainage for more than three days after closure 4 Presence of necrotic or slough tissue at the base of the wound

4 Presence of necrotic or slough tissue at the base of the wound

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to friction and shear? 1 Keep the skin dry and free of maceration 2 Provide pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed

4 Provide a trapeze to facilitate movement in bed

Which type of wound drainage is shown in the image on the next slide? 1 Serous 2 Purulent 3 Sanguineous 4 Serosanguineous

4 Serosanguineous

While changing the wet-to-dry dressing, the nurse notes a dime-sized ulcer under the adhesive tape. What should be applied to secure the wound? Select all that apply. 1 Elastic net 2 Rolled gauze 3 Topper dressing 4 Solid skin barrier 5 Montgomery ties

4 Solid skin barrier 5 Montgomery ties

A patient is receiving negative-pressure wound therapy (NPWT). After the primary health care provider places the device, the nurse applies a foam, polyvinyl alcohol (PVA) dressing. What is the purpose of the dressing? 1 To remove wound debris 2 To prevent wound maceration 3 To stimulate wound contraction 4 To prevent excessive growth of granulation tissue

4 To prevent excessive growth of granulation tissue

Which type of dressing is used for stage I pressure ulcers? 1 Gauze sponges 2 Hydrogel dressings 3 Hydrocolloid dressings 4 Transparent film dressings

4 Transparent film dressings

While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable

4 Unstageable

The health care provider prescribes a dressing that will facilitate autolytic debridement. Which action made by the nurse indicates effective nursing? 1 Using sterile maggots to ingest the dead tissue 2 Using scissors to remove the devitalized tissue 3 Using Dakin's solution to break the necrotic tissue 4 Using hydrocolloid dressings to remove the dead tissue

4 Using hydrocolloid dressings to remove the dead tissue

Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis? 1 Zinc 2 Protein 3 Vitamin C 4 Vitamin A

4 Vitamin A

Arrange in order the steps that the nurse follows while treating pressure ulcers in a patient. 1. Remove the dressing and place it in a plastic bag 2. Position the patient for access to dressing removal 3. Measure the length and width of the pressure ulcer 4. Determine if the patient has allergies to topical agents 5. Determine if the patient needs pain medication

4. Determine if the patient has allergies to topical agents 5. Determine if the patient needs pain medication 2. Position the patient for access to dressing removal 1. Remove the dressing and place it in a plastic bag 3. Measure the length and width of the pressure ulcer

Arrange the steps in order that the nurse follows while irrigating a wound. 1. Place waterproof pad under the patient 2. Remove the gloves 3. Apply gauze pads over surrounding skin 4. Allow the solution to gently flow over wound 5. Pour sterile solution into sterile irrigation containers

5. Pour sterile solution into sterile irrigation containers 1. Place waterproof pad under the patient 4. Allow the solution to gently flow over wound 3. Apply gauze pads over surrounding skin 2. Remove the gloves

While assessing a patient with the Braden Scale, the nurse suspects that the patient is at very high risk of pressure ulcer development. What might be the patient's score? 1 8 2 10 3 13 4 17

8

Distal

Away from the center of the body

Chronologically arrange the steps for using a syringe and needle to collect a sample for a wound culture. 1. Applying suction to the 10-mL mark 2. Removing skin flora with a disinfectant solution 3. Moving the needle back and forward at different angles for two to four explorations 4. Using a 10-mL disposable syringe with a 22-gauge needle

Correct 2. Removing skin flora with a disinfectant solution 4. Using a 10-mL disposable syringe with a 22-gauge needle 1. Applying suction to the 10-mL mark 3. Moving the needle back and forward at different angles for two to four explorations

Proximal

Near the center of the body

A nurse is performing a needle aspiration to obtain a wound culture. In what order will the nurse plan to carry out the steps? 1. Apply suction to the 10-mL mark. 2. Clean the intact skin with a disinfectant solution. 3. Move the needle back and forward at different angles. 4. Take a 10-mL disposable syringe and pull 0.5 mL of air into it. 5. Remove and discard the needle, and prepare the syringe for the laboratory. 6. Insert the needle through the intact skin next to the wound and withdraw the plunger.

The needle should be moved back and forward at different angles for two to four explorations. Lastly, the needle should be removed and discarded safely, the excess air from the syringe should be expelled, and the syringe can be capped and prepared for the laboratory. 2. Clean the intact skin with a disinfectant solution. 4. Take a 10-mL disposable syringe and pull 0.5 mL of air into it. 6. Insert the needle through the intact skin next to the wound and withdraw the plunger. 1. Apply suction to the 10-mL mark. 3. Move the needle back and forward at different angles. 5. Remove and discard the needle, and prepare the syringe for the laboratory.

After asking for the patient's level of comfort using a scale of 0 to 10, how should the nurse order the steps in assessing the patient's pressure ulcer? 1. Measure the width and length of the ulcer. 2. Remove gloves and perform hand hygiene. 3. Determine if the patient has any allergies to topical agents. 4. Describe the procedure to the patient, and remove the dressing. 5. Review the order for topical agents or dressing and location. 6. Review the medical record to assess for any significant weight loss. 7. Note the color and percentage of tissue type present in the wound base. 8. Measure the depth of undermining by using a cotton-tipped applicator. 9. Inspect the periwound skin, checking for maceration, redness, or any denuded areas.

the nurse will remove the gloves and perform hand hygiene. Finally, the nurse should review medical records to assess for any significant weight loss. 3. Determine if the patient has any allergies to topical agents. 5. Review the order for topical agents or dressing and location. 4. Describe the procedure to the patient, and remove the dressing. 7. Note the color and percentage of tissue type present in the wound base. 1. Measure the width and length of the ulcer. 8. Measure the depth of undermining by using a cotton-tipped applicator. 9. Inspect the periwound skin, checking for maceration, redness, or any denuded areas. 2. Remove gloves and perform hand hygiene. 6. Review the medical record to assess for any significant weight loss.