vSIM Josephine Morrow

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, possibly with visible subcutaneous fat. Rationale: The nurse assessed a stage III pressure ulcer, which has full-thickness tissue loss with possible visible subcutaneous fat. A stage I pressure ulcer has intact skin with nonblanchable redness of a localized area. A stage II pressure ulcer has partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. A stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle

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. Rationale: The nurse should ask the patient to press the call button to summon a co-worker who can obtain a clean dressing. Once the dressing touches the bed it is contaminated and should not be used. The nurse should not leave the patient's room in the middle of a sterile dressing change to obtain more supplies. It would be inappropriate to reapply a soiled dressing until a new one can be obtained

The nurse is providing education to Ms. Morrow and her daughter on nutrition. What is the best dietary choice to promote wound healing?

Baked chicken Rationale: Protein is necessary for wound healing. The best dietary choice for Ms. Morrow would be chicken because it is highest in protein. Although whole grain bread, green leafy vegetables, and baked potato are healthy meal choices, they do not promote wound healing

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. Rationale: With a venous stasis ulcer, the nurse would expect to assess brown discoloration around the wound site. Shiny skin on lower extremities with hair loss over legs, feet, and toes would be indicative of peripheral arterial disease. Pale, white toes and decreased sensation are descriptive of Reynaud's disease. Scaly rash between the toes with itchiness can be found with athlete's foot

The nurse is completing an admission assessment on a patient admitted for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition? (Select all that apply.)

Diabetes mellitus Poor circulation Obesity Poor hygiene Rationale: Risk factors for development of a pressure ulcer include Diabetes mellitus, poor circulation, and obesity. Poor hygiene can also contribute to the wound formation. Hypertension is not a risk factor for pressure ulcer development

The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? (Select all that apply.)

Have you noticed any swelling on your feet, ankles, or fingers? Do some areas of your skin seem warmer or colder than others? Have you used pads or special pants because you can't control your urine? Do you have any sores on your body? Rationale: It would be appropriate for the nurse to ask the following questions: Have you noticed any swelling on your feet, ankles, or fingers? Do some areas of your skin seem warmer or colder than others? Do you have any sores on your body? In addition, the question about using pads or special pants because of an inability to control urine may sound like it is about the urinary system, but it is very appropriate for a skin assessment soiled pads and special pants may result in skin breakdown. The nurse would not ask the patient to describe activities that cause fatigue; this would be more appropriate to an activity assessment

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

High risk Rationale: A score of 10-12 is a high risk using the Braden Scale. A score of 19-23 = not at risk, 15-18 = low risk, 13-14 = moderate risk.

The 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 one inch from the upper tip of the wound. Rationale: The correct response is: I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound. The nurse would gently instill the solution rather than using force. The tip of the syringe should not be allowed to touch the wound bed. A sterile specimen cup would not be used to perform wound irrigation

The nurse is performing an assessment of Ms. Morrow's wound. What should be included in the documentation? (Select all that apply.)

Location Drainage Odor Tunneling Rationale: When assessing Ms. Morrow's wound, the nurse should document location of wound, any drainage noted, odor, and presence of tunneling. The nurse would assess skin turgor to determine the patient's hydration status, not to assess a wound.

The nurse is preparing to irrigate a patient's wound. Upon assessment, the wound appears be healing and the wound bed is beefy red. Which solution should the nurse select for this procedure?

Normal saline Rationale: The most commonly ordered solution for wound irrigation is normal saline. Tap water is not sterile and is typically not used in the hospital setting for wound care. Isopropyl alcohol would cause the patient extreme discomfort and may damage the delicate granulation tissue. Dakin's solution is used with wounds that have necrotic tissue

The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status?

Prealbumin Rationale: Although albumin and prealbumin are both indicators of protein nutritional status, prealbumin has a shorter half-life and is a more sensitive measurement of current nutritional status. Both calcium and iron are incorrect and do not represent the patient's nutritional status

The nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the plan of care for this patient? (Select all that apply.)

Provide meticulous skin care. Monitor patient for signs of skin breakdown. Assist with range of motion exercises to lower extremities. Perform neurovascular checks to look for changes. Rationale: When planning care for a patient with edema, the nurse should provide skin care, monitor for signs of skin breakdown, assist with range of motion exercises, and perform neurovascular checks. The nurse would encourage ambulation as tolerated rather than maintain the patient on strict bed rest

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

Purulent Rationale: The nurse would describe this drainage as purulent. Serous drainage is clear and watery, sanguineous is bright red and looks like blood, and serosanguineous is light pink to blood-tinged

The nurse is providing education to Ms. Morrow and her 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. Rationale: The nurse should instruct the patient and her daughter to put antiembolism stockings on Ms. Morrow and that she should wear them all day. The patient should elevate her legs rather than keep them in the dependent position to facilitate venous return to the heart. Skin should be kept moist and should be inspected daily. Patients should participate in an individualized walking program

The nurse is irrigating a patient's wound when the patient complains of pain. What is the appropriate action by the nurse?

Stop the procedure and administer the ordered analgesic. Rationale: The nurse should stop the procedure and administer the ordered analgesic. After allowing an adequate amount of time to pass, the nurse can gather new supplies and begin again. The nurse should not wait until after the procedure to medicate the patient. Although the nurse would want to assess the patient, the procedure should not continue until the patient has received the analgesic. Wound irrigation can be uncomfortable for the patient, and it would be inappropriate to notify the provider prior to medicating the client

Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's wound. What is the appropriate response by the nurse?

The procedure helps remove drainage and debris from the wound. Rationale: Irrigation helps remove drainage and debris from the wound. The fluid is not used to hydrate the tissue surrounding the wound, nor is it used to sterilize the wound. The solution most commonly used for irrigation is 0.9% normal saline, which does not contain medication.

The nurse has received an order to apply a hydrocolloid dressing to Ms. Morrow's right lower extremity. Which statement, if made by the nurse, would indicate the need for further education?

This dressing will need to be held in place by surgical tape. Rationale: Hydrocolloid dressings are self-adhesive, so further teaching would be indicated if the nurse said, "This dressing will need to be held in place by surgical tape." Hydrocolloid dressings help to maintain a moist wound environment, can be left in place for three to seven days, and help protect the wound from contamination