introduction to nursing (SHERPATH) WEEK 7 & 8

Which statement indicates the nurse has a correct understanding about the different types of patient dressings?

"I will avoid using hydrocolloids for infected wounds." This statement indicates understanding. Hydrocolloids are inappropriate for infected wounds due to their occlusive properties and long wear time; therefore they are avoided.

Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound?

"My wound will look beefy red within 1 week." - If the wound looks beefy red within 1 week, that indicates granulation tissue is forming and the wound is healing, which is normal. This statement indicates successful teaching.

Which statements by the nurse caring for a postoperative patient who suffered a spinal cord injury indicate correct understanding about assessment tools?

"The Norton Scale is used to assess for pressure injury risk." - The Norton Scale is a tool used to assess risk for developing pressure injuries, and it indicates a correct understanding about assessment tools. "When assessing for open wounds, I can use the Wound Characteristic Instrument." - Wound Characteristic Instrument is a tool used to assess open wounds and to track wound healing.

Which statement indicates the nurse has a correct understanding of a patient's pressure-reducing bed?

"The support surface may be foam or gel." A pressure-reducing support surface may be foam or gel, so this statement indicates a correct understanding.

Which statement describes the main purpose of the Nursing Minimum Data Set (NMDS)?

- To standardize the collection of essential nursing data The purpose of the NMDS is to standardize the collection of essential nursing data using standardized terminology and accurate descriptions of nursing diagnoses, nursing care, outcomes of care, and nursing resources.

Which Braden Scale score range would alert the nurse that a patient is at moderate risk for pressure injury development? Record your answer as whole numbers separated by a hyphen. __

13-14 - If the patient is at moderate risk for pressure injury development, the Braden score will be 13‐14.

Using military time, at what time would the nurse turn the patient if the patient was last turned at 1 p.m.? Record your answer as a whole number. __

1500 - The patient is turned every 2 hours. If the patient was turned at 1 p.m. (1300 military time), the patient would be turned at 1500.

Which pressure injury stage is depicted in the image?

2 The nurse would classify this as a stage 2 pressure injury. It is a partial-thickness wound involving the epidermis and dermis.

Which patient situations are of immediate concern?

A patient is experiencing shock. - A patient experiencing shock is of immediate concern because the condition is life-threatening. A patient is profusely bleeding from a wound. - A patient who is bleeding profusely is of immediate concern because the situation is life-threatening. A patient has an eviscerated wound. - A patient who has an eviscerated wound is of immediate concern because the situation is a medical emergency.

Which patient situations would prompt the nurse to question a prescription for heat therapy?

A patient with a local tooth abscess - The nurse would question this prescription. Heat therapy is not used with abscesses, as it may cause the abscess to rupture. A patient with possible appendicitis - The nurse would question this prescription. Heat therapy is not used with possible appendicitis, as it may cause the appendix to rupture. A patient with bleeding from a small wound - The nurse would question this prescription. Heat therapy is not used with active bleeding, as it increases bleeding.

Which patient would the nurse see first after receiving report?

A patient with a profusely bleeding wound - The nurse would see the patient with a profusely bleeding wound first because it is life-threatening.

Which definition of a fistula is correct?

Abnormal connection between two internal organs A fistula is an abnormal channel between two internal organs or between an internal organ and the skin.

Which strategy would the nurse use to classify a burn?

According to the skin layer damaged - Classifying the burn according to the skin layer damaged is a common strategy, and the categories include superficial, partial thickness, and full thickness.

Which primary parameters are measured when using the Norton Scale?

Activity Activity is a parameter measured by the Norton Scale. Mobility A primary parameter on the Norton Scale is mobility. Mental state Mental state is a parameter assessed by the Norton Scale.

Which steps are involved in measuring wound undermining?

Administer pain medication. Some patients may require pain medication to withstand the procedure to measure wound undermining. Laterally insert the cotton-tipped applicator into the widest section. To measure wound undermining, the cotton-tipped applicator must be inserted laterally into the widest part of the wound. Mark the area on the stick end of the applicator that is even with the edges of the skin. The area on the stick must be marked to measure the wound undermining. Measure the distance from the top of the applicator to the marked area. Measuring the distance from the top of the applicator to the marked part of the stick helps determine actual depth.

The nurse would use which organization's guidelines to direct care for a patient's back wound?

Agency for Healthcare Research and Quality (AHRQ) - AHRQ provides evidence-based practice for wound care guidelines, and the nurse would use its guidelines.

Which phrase provides the rationale for using standardized nursing terminology when treating a patient as part of a multidisciplinary nursing team?

Allows all nurses to use the same vocabulary to facilitate communication - Standardized nursing terminology effectively avoids the use of synonyms in medical terms, thereby avoiding confusion and promoting understanding among health care providers.

In which way does standardized nursing terminology directly enhance patient care?

Allows health care providers in different departments to better understand each other's reports - Standardized nursing terminology enhances patient care by facilitating better communication among health care providers in different departments.

Which factors can place a patient at risk for a pale, dry wound?

Anemia - When a wound bed is pale or dry, it can indicate anemia, which is when the blood does not contain enough red blood cells. Diabetes - Diabetes can contribute to a nonhealing wound that presents with a pale, dry wound bed. Vascular disease - Vascular disease can be a contributing factor that presents with a pale, dry wound bed because of the decreased perfusion to the wound. Nutritional deficiencies - Nutritional deficiencies can cause a wound bed to be dry and pale. Nutritional deficiencies can delay wound healing.

Which action describes a Quality and Safety Education for Nurses (QSEN) knowledge-based competency?

Applying technology to patient safety - A QSEN competency advocates for the application of technology management tools to support safe patient care.

Which action would the nurse take for a mother who calls the clinic reporting that a thick yellowish drainage is leaking out of her daughter's surgical leg incision and the incision edges are red and warm?

Ask the mother to bring her daughter to the office to be evaluated by the surgeon immediately. Suggesting that the patient come into the office to be evaluated by the surgeon immediately is the action to take because the scenario indicates the wound is likely infected.

Which nursing actions involve the use of informatics?

Assessing and evaluating data - Nursing use of informatics includes the ability to review, assess, and evaluate patient data and information. Supporting nursing research - Nursing use of informatics includes the support of nursing research through the understanding and acquisition of data. Delivering informed health care education - Nursing use of informatics includes the ability to deliver evidence-based health care education.

The nurse is caring for a patient admitted with opioid use disorder. Match the electronic health record benefit with the step used in patient care.

Assessing opioid blood level - System connectivity Determining health care needs - Point-of-care information Providing external provider support - Remote access Using CPOE to manage prescriptions - System integration

Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement?

Autolytic The nurse is monitoring autolytic debridement, the slowest type of wound debridement, in which the body uses its own enzymes and phagocytic cells for healing.

Which cells join the epidermis and dermis and are arranged in a single layer?

Basal cells Basal cells compose a single layer of active cells that join the epidermis and dermis.

Which type of opening occurs in a patient who has an enterocutaneous fistula?

Between the skin and the intestine - An opening between the skin and the intestines is described as enterocutaneous. "Entero" means intestines, and "cutaneous" means skin.

Which function will be compromised if the dermis is injured?

Blood supply to the skin Supplying blood to the skin is a function of the dermis; thus, if this area is injured, the blood supply will be negatively affected.

Match the unexpected skin assessment finding to its description.

Blue skin - Cyanosis Pinpoint, flat, red spots - Petechiae Red skin - Erythema Bruise - Ecchymosis

Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity?

Bone - Bone is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate. Tendon - Tendon is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate. Muscle - Muscle is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate.

Which evaluative cue would alert the nurse that a patient with a pressure injury is declining?

Braden Scale score was a 9 but is now an 8. - A Braden Scale score that decreases indicates the patient is declining. The lower the score, the higher the risk for pressure injuries.

Which wound is classified as a closed wound?

Bruise A bruise is classified as a closed wound because the skin is intact.

Which foods would the nurse recommend for a patient with a leg wound who needs to increase vitamin A intake?

Carrots Carrots are high in vitamin A, so the nurse would recommend them. Sweet potatoes The nurse would recommend sweet potatoes because they are high in vitamin A.

Which classifications are used to identify wounds?

Cause Cause is a classification for wounds. For instance, a wound can stem from intentional causes, such as a surgery, or unintentional causes, such as an accident. Depth Depth is a classification for wounds. For instance, a wound can be classified as superficial, partial thickness, or deep or full-thickness. Contamination level Contamination level of infection is a classification for wounds. For instance, a wound can be classified as clean or dirty. Healing time Healing time is a classification for wounds. For instance, a wound can be classified as acute (heals quickly) or chronic (takes much longer than expected to heal).

Which items would the nurse obtain to initiate vacuum-assisted wound closure for a patient?

Clear adhesive drape The nurse will need a clear adhesive drape to prepare the site. Suction tubing The nurse will need suction tubing to attach to the suction device and wound dressing. Foam sponge A foam sponge is needed for placement into the patient's wound. Negative-pressure setting device A negative-pressure setting device is needed for vacuum-assisted wound closure to work properly.

Match the type of wound drainage to the color of fluid the nurse would observe on a patient's dressing.

Clear and watery - Serous Pink to pale red - Serosanguineous Bright red - Sanguineous Greenish, yellow - Purulent

Match the standardized terminology to its content.

Clinical data elements for use in all nursing settings - NMDS: Nursing Minimum Data Set Nursing diagnoses - NANDA-I: NANDA International Diagnoses, interventions, and outcomes - CCC: Clinical Care Classification Nursing administrative data elements for use in all nursing settings - NMMDS: Nursing Management Minimum Data Set

Which nursing skill level of informatics is demonstrated by a nurse who understands long-range goals but does not make judgments based on patient data?

Competent - A nurse with competent informatics skills understands long-range goal terms that assist in the interpretation of data and information.

The new nurse is learning to use the electronic health record (EHR). Which knowledge and skills must nurses have to effectively use the EHR?

Computer literacy - Use of the EHR requires basic computer literacy or understanding how a computer works. Lack of computer literacy could have safety, security, and accuracy implications. Password protection and security - Data security is a major component of the EHR requiring individual passwords that are not to be shared. Understanding password protection and security strengthens the safety and security of patient information. Communication management - The EHR allows for interdisciplinary communication ensuring that patient needs are met, care plans reflect current information, and cost-containment measures are effective, such as not repeating diagnostic tests already performed.

The nurse is preparing a patient for discharge. Which technology would help with discharge planning?

Computerized provider order entry (CPOE) system - The CPOE system will allow electronic medication ordering that can benefit the patient at discharge.

Which interpretation would the nurse make about a wound that is colonized?

Contains microorganisms on the surface of the wound only - A colonized wound contains one or more microorganisms on the surface of the wound, with no clinical signs of a wound infection.

Which cues related to skin integrity may reflect an overall health problem?

Cracking - Extreme dryness or cracking adversely affects skin integrity, indicating an overall health problem. Tenting - Tenting indicates the patient is dehydrated and reflects an overall health problem. Pathogens identified in a wound culture - A wound with pathogens indicates an infection, which is an overall health problem.

Which report drove the use of informatics in nursing?

Crossing the Quality Chasm: A New Health System for the 21st Century - Crossing the Quality Chasm: A New Health System for the 21st Century suggested the need for fundamental changes in health care including strengthening clinical information systems.

A patient's blood pressure and temperature are examples of which informatics construct?

Data -, A patient's blood pressure and temperature are examples of data. Data are single facts, observations, and measurements that can be used as a basis for reasoning, discussion, or calculation.

Place the concepts of knowledge in informatics in order from shallow to applied.

Data Information Knowledge Wisdom

Which complication would the nurse identify for the health care provider in a patient whose surgical incision "popped" open and is draining fluid?

Dehiscence - Dehiscence is a partial or complete separation of tissue layers and includes a "popping" sound with an increase in drainage. This accurately describes the scenario.

Which components are likely damaged when the nurse chooses the hypothesis Impaired Skin Integrity for a patient?

Dermis The dermis would be damaged if Impaired Skin Integrity is the hypothesis. Skin layers are affected. Epidermis The epidermis would be damaged if Impaired Skin Integrity is the hypothesis, indicating skin layers are affected.

Which information should be included in an ANTICipate hand-off report?

Details about the patient's intubation procedure - The ANTICipate model's (N) new clinical information and (T) tasks performed should be included information. Planned treatment if the patient's condition worsens - The ANTICipate model should include information about (C) contingency plans. Change in the patient's status from "critical" to "serious" - The ANTICipate model should include information about changes in the (I) patient's illness severity.

Which term would the nurse use to describe excessive moisture on the patient's skin?

Diaphoresis Diaphoresis is excessive moisture on the patient's skin, and it is usually visible to the nurse and patient.

Nursing documentation is both a patient care and legal process. Which actions would indicate that the nurse requires further education on the legal implications of documentation?

Documenting patient data in front of other colleagues - Patient-related documentation should be done privately to protect the confidentiality of patient information. Using white correction fluid to correct an error on a paper chart - Documentation should never be obliterated. Error correction in a paper chart should follow accepted measures such as drawing a single line through the error, noting the correct response, and initialing and dating the entry. Completing documentation at the end of shift - Leaving documentation until shift end places a risk of not adequately remembering essential patient-related data and may encourage rapid and possible minimal data entry as a result of time constraints (e.g., need to end shift).

Decision-making in health care is facilitated using clinical decision support systems (CDSSs). Which descriptions pertain to specific CDSSs?

Eases the ability to schedule patient care needs - A computerized provider order entry (CPOE) system allows health care providers to easily enter prescriptions for medications, diagnostic testing, and patient care equipment. Provides health care information on patient allergies - Point-of-care alert systems notify health care providers when issues related to allergies, drug interactions, and medication dose alerts occur during care. Allows nurses to develop patient care plans - Workflow support systems help nurses understand and manage patient care flow, including medication reconciliation, patient assessments, and focused workflows.

Which finding is expected in a physical skin assessment?

Elastic skin turgor Elastic skin turgor is an expected finding during a physical skin assessment.

Which standard electronic health record (EHR) component is required for patient care?

Electronic medication system - All EHRs are required to have a system for electronically monitoring medication distribution to help reduce medication errors.

The nurse is caring for a patient experiencing chest pain. Which benefits of the electronic health record (EHR) would help the nurse care for this patient?

Enables visualization of the patient's blood pressure, latest electrocardiogram, and oxygen saturation - The EHR provides dashboards allowing rapid visualization of multiple types of patient clinical indicators and data. Enables visualization of laboratory test trends through access to laboratory data - The EHR provides access to all patient diagnostic testing to visualize trends in laboratory data such as cardiac enzymes. Provides access to all health care provider notes for input - All health care provider notes are able to be seen to guide a plan of care.

In which way can nurses perform effective hand-off reporting?

Ensure that complete and accurate information is conveyed. - Effective hand-off reporting is achieved by ensuring that accurate, complete, and essential information is shared for continuity of care.

Which cues would the nurse observe for a patient with an infected lateral malleolus wound?

Erythema noted on the superior portion of the wound - Erythema of the superior portion of the wound indicates the wound may be infected. Purulent, malodorous drainage - Purulent, malodorous drainage is a sign of an infected wound. Temperature of 102°F (38.9°C) - A temperature of 102°F (38.9°C) is a sign of an infection, and it would be a cue that the nurse observes.

Which complication allows visceral organs to be exposed through an incision?

Evisceration Evisceration is the total separation of tissue layers, allowing protrusion of visceral organs through an incision.

Which cue about a wound is an immediate concern?

Excessive bleeding Excessive bleeding is hemorrhage, an immediate concern.

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat?

Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week. - Because the overall outcome is healing of the wound, this outcome demonstrates progressive healing of wound.

Match the pressure injury stage to its characteristics.

Extends into the subcutaneous tissue but not the fascia - stage 3 Intact, nonblistered skin - stage 1 Full-thickness wound with eschar - unstageable Involves the epidermis and dermis - stage 2

Match the type of wrap the nurse would use for each injured body part.

Extremities - Spiral Joints - Figure 8 Head - Recurrent

In which way does the use of standardized nursing terminology contribute to advances in the field of nursing?

Facilitates measurement of the impact of nursing interventions on patient outcomes - The use of standardized nursing terminology facilitates measurement of the impact of nursing interventions on patient outcomes. This measurement, in turn, demonstrates the contribution of nursing care to health care outcomes.

Which food would the nurse suggest the patient consume to increase zinc in the diet for wound healing?

Fish Fish is a high-protein food; zinc is found in high-protein foods.

The nurse is documenting patient care using a non-problem-oriented team approach. Which type of documentation is the nurse using?

Flowsheet documentation - Flowsheet documentation uses abbreviated forms of documentation generally recorded on a regular basis.

Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of wound drainage?

Foam - The nurse would anticipate using a foam dressing. It is indicated for moderately to highly exudative wounds because it pulls fluid away from the wound while maintaining a moist environment.

Which federal regulation established the protection of patient information?

HIPAA - The Health Insurance Portability and Accountability Act (HIPAA), a federal law with both the Privacy and Security Acts, established national standards for the protection of personal health information.

Which statements regarding HIPAA are true?

HIPAA outlines legal penalties for health care providers who breach security of health care data. - HIPAA laws include legal penalties for any health care staff who breach security of health care data. Nurses are legally and professionally responsible for understanding HIPAA. - When using information technology, nurses are legally and professionally responsible for understanding all related laws and regulations, policies and procedures, as well as the ethical codes of their employers and professional organizations. HIPAA sets standards for how confidentiality of health care information must be maintained. - HIPAA includes standards for how security and confidentiality of health care information must be maintained.

Which question would the nurse ask to determine the patient's health history about skin integrity?

Has anyone in your family had a skin disorder? A question about the patient's genetics regarding skin disorders does help the nurse determine the patient's health history about skin integrity.

Which patient scenario would prompt the nurse to question a prescription for cold therapy?

Has edema present Having edema would cause the nurse to question cold therapy. Cold therapy slows absorption of fluid from the vasoconstriction, causing edema to last longer.

Which cue is relevant for a patient who has a wound?

Having a low prealbumin level A low prealbumin level is a relevant cue regarding a wound because it indicates that protein levels are low and could affect wound healing.

Match the type of healing to its characteristic.

Healing is from the bottom and sides of the wound. - Secondary intention Edges are approximated. - Primary intention There is a delay between injury and closure. - Tertiary intention

Which response is likely when a patient who has a full-thickness wound receives a steroid?

Healing time will slow. - Steroids, which are antiinflammatories, interrupt the inflammatory process, making patients prone to infections and slow healing.

Which components comprise the I-PASS hand-off process?

Identifying patient acuity I-PASS includes a standardized one-word representation of the patient's acuity or "Illness severity." Time for the receiving nurse to ask question I-PASS includes time for the nurse receiving the patient to ask questions or a "Synthesis by the receiver." Patient treatment plan I-PASS includes a summary of the patient's treatment plan and diagnosis or "Action list."

Which hypothesis would the nurse select for a patient with a breakdown in the dermis from external forces?

Impaired Skin Integrity - The nurse would select Impaired Skin Integrity because the dermis (skin) has a break in the integrity.

For which patient hypotheses would the nurse select turning and positioning as a solution?

Impaired Skin Integrity - Turning and positioning is a solution for Impaired Skin Integrity. Risk for Pressure Ulcer/Injury - Turning and positioning is a solution for Risk for Pressure Ulcer/Injury. Impaired Tissue Integrity - Turning and positioning is a solution for Impaired Tissue Integrity. Risk for Impaired Skin Integrity - Turning and positioning is a solution for Risk for Impaired Skin Integrity.

Which factors can make a patient prone to pressure injuries?

Inactivity Inactivity can lead to pressure injuries from prolonged pressure. Immobility Immobility can lead to pressure injuries from friction, shear, and prolonged pressure. Incontinence Incontinence can increase the risk for pressure injuries from excess moisture on the skin. Malnourishment Malnourishment can increase the risk for pressure injuries because of the lack of nutrients going to the cells.

Match the type of documentation error to its probable result.

Inappropriate order of care - Late entry Missing medication dose - Omission Misinterpretation - Erroneous abbreviation Patient care not validated - Lack of clarity

Which statements exemplify the core principles of incident reporting?

Incident reporting provides an opportunity to learn from errors. - A major purpose of incident reporting is to promote learning to create an organizational culture of safety. All individuals must be able to report an incident without blame. - Reporting must be safe and not include blame. It is not a punitive process. Incident reporting should result in positive changes related to patient care and safety. - Reporting should lead to a constructive response, including recommendations for changes creating an organizational culture of safety.

Match the documentation type to its description.

Includes rows and columns for assessments and outcomes - Flowsheet Is the most used problem-oriented method - SOAP Requires evaluation of nursing intervention - PIE Incorporates established best practices for patient outcomes - Clinical pathway

Which benefit do electronic tablets in patient care units provide?

Includes the patient in health care - Electronic tablets help the patient be a partner in their care allowing them to see their test results.

Which phrase describes the purpose of informatics competencies for nurses?

Information literacy for patient safety and care quality - Informatics competencies in nursing care ensure the ability to use information literacy to improve patient safety, care quality, and cost reduction through the understanding of data and information.

Which two major fields compose the essence of nursing informatics?

Information science - Information science, an interdisciplinary discipline, is essential in supporting nursing informatics work. Computer science - Nursing informatics integrates nursing, computer, and information science for the management and communication of data, information, knowledge, and wisdom.

Match the appropriate informatics term with its definition or use.

Intersystem communication - Interoperability Funding to increase electronic health record (EHR) use - Meaningful use Outcome of behavior - Unintended consequence Understanding right and wrong - Ethics

Which characteristic accurately describes the dermis?

Is an area for sebaceous glands - Sebaceous (oil) glands are located in the dermis.

Which question would the nurse ask about an online health information website to verify its content?

Is the information found in other sources? - Determining that the information can be found in other credible sources verifies the content.

Which questions would the nurse ask about an online health resource to determine the objectivity of the resource?

Is there evidence bias in the website? - Determining if there is evidence bias evaluates the objectivity of the website. What are the goals of the website? - Determining the goals of the website evaluates the objectivity of the website. Is bias explicit or hidden? - Determining if bias is explicit or hidden evaluates the objectivity of the website.

Which statement regarding the skin is accurate?

It is closely linked to personal identity.Skin is closely linked to personal identity and self-image.

Which interpretation would the nurse make about a patient's wound culture that is positive?

It is infected. A positive wound culture indicates the patient's wound is infected.

Ethics is an integral part of health care. Which concepts are considered fundamental principles of ethics?

Justice - Justice is the fundamental ethical principle that all patients/individuals are treated fairly. Nonmaleficence - Nonmaleficence is the fundamental ethical principle that health care providers should, above all, do no harm. Autonomy - Autonomy is the fundamental ethical principle that explains how the health care provider should always respect the view of the patient.

Which action for skin hygiene would the nurse take for an obese patient who is immobile?

Keep skinfolds dry from perspiration. The nurse would keep the skinfolds dry. In an obese patient the skinfolds must be kept dry from perspiration to prevent skin breakdown.

Which intervention would the nurse implement for a patient with an open drain?

Keep the safety pin in place. - The safety pin is kept in place to prevent the tube from slipping back inside the body; the nurse would implement this intervention.

Which obesity factors contribute to a nonhealing wound?

Lack of blood vessels in adipose tissue A lack of blood vessels in adipose tissue is an obesity factor that can contribute to nonhealing wounds. Undue pressure on wound edges An obesity factor that can contribute to nonhealing wounds is undue pressure on wound edges. Decreased oxygen and nutrients to the wound An obesity factor of decreased oxygen and nutrients to the wound can lead to nonhealing wounds.

Which parameters would the nurse assess when performing a focused wound assessment?

Location Location is important to assess, note, and document during a focused wound assessment. Drainage The nurse would assess drainage during a focused wound assessment to determine color, amount, odor, and consistency. Wound bed The wound bed is assessed because it will indicate if healing is present or not. Presence of tunneling Presence of tunneling is important to assess during a focused wound assessment because deep tunneled areas may lead to abscesses and infection.

Which characteristics of aging cause the skin to be fragile, loose, dry, and transparent?

Loss of elastin - Gradual loss of elastin causes skin to age and become loose. A decrease in the number of sweat glands - A decrease in the number of sweat glands causes dry skin. A smoothing of the layer of skin under the epidermis - A smoothing of the layer of skin under the epidermis causes skin to become more fragile.

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity?

Low prealbumin levels - Low prealbumin level is a cue for Impaired Skin Integrity because it can affect healing. Immobility - Immobility is a cue for Impaired Skin Integrity because it can lead to prolonged pressure. Stage 2 pressure injury - A stage 2 pressure injury is a cue for Impaired Skin Integrity because it affects the epidermal and dermal layers of the skin.

Which term describes the last phase of wound healing?

Maturation Maturation, or remodeling, is the last phase of wound healing. During maturation, collagen continues to be deposited, and scars are formed and strengthened.

Which steps would the nurse take to measure the dimensions of a sacral pressure injury?

Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. - The depth of a wound is found by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. Measure the width laterally from left to right at the widest portion of the wound. - The width is found by measuring laterally from left to right at the widest portion of the wound. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. - The depth of the undermining constitutes part of measuring the depth of the wound, and it is found by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. Measure the length vertically from the top to the bottom at the widest open area of the wound. - The length of a sacral pressure injury is determined by measuring vertically from the top to the bottom at the widest open area of the wound.

Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)?

Monitor for granulation tissue in the wound. - The purpose of NPWT is to stimulate granulation tissue formation. Avoid using NPWT for a patient with a cancerous wound. - NPWT is not used for malignant (cancerous) wounds. If the patient reports pain, change from the black foam to white foam. - If the patient reports pain, the nurse can switch from the black foam to the white foam. Report to the health care provider if there is an increase in wound drainage. - If the patient has an increase in wound drainage, the patient is declining, and the nurse notifies the health care provider.

Which solution would the nurse obtain to clean a patient's arm wound?

Normal saline Normal saline is the solution of choice because it is readily available; it does not harm cells needed for healing.

Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage?

Notify the primary health care provider. - The nurse would notify the primary health care provider because the wound is infected. Take the patient's temperature. - The nurse would take the patient's temperature because the patient's wound is infected. Review white blood cell count. - The nurse would review the patient's white blood cell count because the patient's wound is infected.

Which actions would the nurse take for a patient receiving heat therapy?

Obtain distilled water for aquathermia treatments. - The nurse would obtain distilled water for aquathermia treatments because this is the recommended action. Check on the disoriented patient more frequently. - The nurse must check on disoriented patients more frequently because disoriented patients cannot report changes. Cover the container and hand when providing warm hand soaks. - The nurse would cover the container and hand to help maintain the temperature of the solution.

The nurse is caring for a postoperative patient. Which documentation would be needed when an unexpected opioid-related event requires the completion of an incident report?

Original pain medication prescription - The original medication prescription must be included to determine what the patient should have received. Date and time of the incident - The date and time of the incident are objective facts that should be included in the incident report. Name of the nurse who administered the medication - Names of all individuals present at the time of the incident would be included and beneficial to the investigation process.

Which parameters would the nurse monitor after applying a wrap to an ankle?

Pain - Pain is one of the five Ps and would be monitored. Pallor - Pallor is one of the five Ps and would be monitored. Paralysis - The nurse would monitor for paralysis because it is one of the five Ps. Paresthesia - The nurse would monitor for paresthesia because it is one of the five Ps. Pulselessness - Pulselessness is one of the five Ps and would be monitored.

Match the wound bed condition to its cues.

Pale, soft, wrinkled - Macerated Beefy red, shiny, moist - Granulated Black, hard, dry - Necrotic Purulent yellow - Infected

Which assessment technique indicates the nurse properly determined if the patient's incision is healing or is becoming infected?

Palpating the area of induration around the incision line - Palpating the area of induration is an effective way to assess if an incision is healing or becoming infected; an infected incision will have induration (hardness) around the incision.

Match the documentation needs to the type of incident.

Patient name, outcome, labeling, written prescription, responsible person - Medication error Location, date and time, fall circumstances, injury level - Patient fall Location, date and time, event description, injuries, harm level - Equipment malfunction Date and time, chronology, witness names, injury severity, person disposition - Staff injury

In which areas has the application of information technology in health care resulted in major improvements?

Patient safety - The application of information technology in health care has resulted in major improvements in patient safety, such as fall reduction. Health care costs - The application of information technology in health care has resulted in reduction of health care costs, for example, by reducing repeat diagnostic tests. Decision-making - The application of information technology in health care has resulted in major improvements in clinical decision-making. Clinical Decision Support Systems provide aggregated information for clinicians to make health care decisions.

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.

Patient who is experiencing shock from a profusely bleeding wound Patient who just had an incision eviscerate Patient with a stage 4 pressure injury ***The patient experiencing shock from a profusely bleeding wound is seen first because this is life-threatening, and the wound is bleeding (ABCs). Next is the patient with an evisceration; although still a medical emergency, it is not as critical as active bleeding. The patient with a stage 4 pressure injury is seen last because it is a chronic condition.

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound?

Patient will eat a high-protein diet at every meal. - A SMART outcome is specific, measurable, achievable, and relevant (high-protein diet). It also must have a time frame (at every meal). Patient will help with transfers within 24 hours. - A SMART outcome is specific, measurable, achievable, and relevant (help with transfers). It also must have a time frame (within 24 hours).

Which patient is likely at risk for developing a pressure injury?

Patient with unrelieved pressure who has a fractured hip - The patient with unrelieved pressure is most at risk for developing a pressure injury, because tissue ischemia can form and lead to pressure injuries.

Which expected outcome would the nurse select for a patient who has a hypothesis of Pressure Ulcer/Injury?

Patient's Braden Scale score will stay the same or increase within 72 hours. - A Braden Scale score that stays the same or increases is an expected outcome for Pressure Ulcer/Injury. It is a measurable outcome that is related to the hypothesis.

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident?

Patient's wound will exhibit granulation tissue in the wound by 1 week. - A break in the skin from external forces, such as trauma or an accident, indicates a wound; thus, this goal would directly relate to the break in skin from external forces

The nurse is caring for a patient in a medical facility. Which patient information is protected by multiple ethical and federal regulations?

Personal health information - Personal health information or PHI is any health-related information that can be linked to an individual's health status.

The nurse made an error in documenting a patient's care. Which method would the nurse use for correcting a documentation error in a paper chart?

Place the nurse's initials beside the error, and draw a line through the error. - An error should be documented by placing a single line through the error, writing the correct information above or below the line, and including the nurse's signature.

Which technique would the nurse use to turn a patient?

Position patient's body laterally at 30 degrees. The nurse would position patient laterally 30 degrees when side-lying to avoid direct pressure on bony prominences.

Which cues are relevant for an infected wound?

Positive culture growth An infected wound would produce a positive culture growth. Purulent drainage Purulent (pus) drainage is a relevant cue for an infected wound. Induration around edges Induration (hardness) around edges is a relevant cue for an infected wound.

Which primary objective does the proliferative phase of wound healing achieve?

Producing granulation tissue The proliferative phase begins the process of producing granulation tissue that is red and beefy in appearance.

Which phase of wound healing is characterized by a patient who reports that the bumpy and granular injured site "bleeds easily"?

Proliferative - The proliferative phase is the phase of healing and repair in which new tissue bleeds easily and has a granular and bumpy texture.

Which factors can directly cause the fibroblasts and collagen to be altered or ineffective in the proliferative phase of wound healing?

Prolonged decrease of oxygen perfusion to skin - A prolonged decrease of oxygen perfusion to the skin reduces the production of cells that produce collagen (fibroblasts) and decreases collagen formation. Lack of protein - A lack of protein would directly affect collagen because protein is needed for fibroblasts to make collagen. Lack of vitamin C - A lack of vitamin C would directly affect collagen because vitamin C is needed for collagen formation History of diabetes - Diabetes leads to a decrease in collagen synthesis and strength. Thus, diabetes directly affects collagen.

Which factor that affects skin integrity is depicted in this image?

Prolonged pressure Prolonged pressure can damage bony prominences and pressure areas on the body, which are depicted in this image.

Which overall goal would the nurse develop for a patient with a leg incision?

Promote complete healing of wound. - The overall goal for a patient with a wound is to promote complete healing of the wound.

Which action by the nurse is priority when providing discharge teaching to a patient and spouse about wound care when the spouse is the primary caregiver?

Provide written instructions. - The priority is to provide written instructions for the spouse because the spouse is the primary caregiver and will need reinforcement of learning at home.

Which description regarding the subcutaneous skin layer is correct?

Provides a cushioning effect The subcutaneous skin layer, which consists of adipose tissue, provides a cushioning effect for internal organs.

Which functions are provided by the electronic health record (EHR)?

Provides a holistic view for care planning through dashboards showing multiple levels of patient data - EHR dashboards allow rapid access to multilevel patient data, providing a holistic view of the patient's status. Is an effective replacement for paper records - The EHR has proven to be an improved form of paper records, allowing access to data from many areas. Decreases medication errors related to dosing - EHRs have alert systems that indicate when incorrect medication doses are being prescribed or administered.

The nurse is caring for a patient transferred from the intensive care unit to the unit. In which ways would the use of standardized nursing language contribute to more favorable patient outcomes?

Provides documentation consistency - The use of standardized nursing language provides documentation consistency across units and disciplines. Facilitates communication - Using standardized nursing language improves communication among nurses and other health care providers. Enables data trending across units - Standardized nursing language enables data collection and allows trending of care across units.

Which purpose did the Health Information Technology for Economic and Clinical Health (HITECH) Act serve?

Provides funding for the meaningful use of electronic health records - HITECH was created to provide funding for the meaningful use of electronic health records through incentives provided to health care providers and institutions.

Which features describe the subcutaneous layer of skin?

Provides insulation to protect against both heat and cold - The subcutaneous layer does provide insulation to protect against both heat and cold. Cushions bony prominences and internal organs - The subcutaneous layer does provide cushioning for bony prominences and protection of internal organs.

Which are primary functions of the electronic health record?

Provides patient information for planning care - The electronic health record enables the use of accurate, up-to-date patient-related information to help nurses plan care. Provides interdisciplinary documentation review - The electronic health record provides an interdisciplinary approach to patient care by allowing all health care providers to see patient information for better patient care decisions. Allows access to decision support tools for ease of care - The electronic health record allows access to all patient care areas, often as dashboards, for help in health care decision-making.

Which phrase describes a use of information technology in nursing education?

Provides virtual immersion scenarios - Nurses can experience virtual immersions related to information technology through education, such as using technology tools in a virtual presentation.

Which scientific fields are encompassed within the broad academic field of informatics?

Public health science - Informatics is a broad academic field including public health science that focuses on the application of informatics to disease surveillance for populations. Computer science - Informatics is a broad academic field including computer science to discover, manage, and communicate data to support health care. Medical science - Informatics is a broad academic field including medical science that focuses on the diagnosis and management of disease. Information science - Informatics is a broad academic field including information science to discover, manage, and communicate data to support health care.

Match the type of wound to its typical colors.

Purple or maroon - Suspected deep-tissue injury White, brown, or black - Full-thickness burn Beefy red and bumpy - Wound in proliferative phase Red and purulent - Infected wound

Which action would the nurse take when caring for a patient's Jackson-Pratt drain?

Reactivate the drain after emptying. - The nurse would reactivate the drain after emptying. The Jackson-Pratt drain works by suction and must be reactivated or recompressed after emptying.

Which effect on the wound would likely occur if a patient with pressure injuries smoked?

Receives less oxygen - The wound would receive less oxygen because of vasoconstriction and hemoglobin's decreased ability to transport oxygen.

Which phrase describes the main purpose of completing an incident report?

Records details of an incident and begins the process of a quality improvement investigation - The purpose of completing an incident report is to document the details of the incident immediately to ensure accuracy and to begin the process of an investigation.

Which change is associated with aging of the skin?

Reduced insulation and cushioning, resulting in an increased risk for skin trauma and heat loss Reduced insulation and cushioning increase the risk for skin trauma and heat loss. Without cushioning over bony prominences, older adults are at risk for injuries to the skin.

Which response is a result of poor perfusion to the skin?

Reduced production of fibroblasts Poor perfusion leads to a reduced production of fibroblasts, cells that produce collagen.

Match the technology with its benefit.

Reduces human error - Electronic health record (EHR) Dosage accuracy - Computerized Provider Order Entry (CPOE) Healthy behavior monitoring - Wearables Increases access to care - Telehealth

Which benefits does nursing use of informatics in health care provide?

Reducing medical errors - Informatics helps to reduce medical errors through the use of alert systems and practice standards. Reducing health care costs - Informatics helps reduce health care costs by providing real-time information about what diagnostic testing has been done, negating the need for repetitive testing. Increasing data sharing - The use of informatics in health care provides the nurse an environment that allows data sharing across disciplines.

Which cue alerts the nurse that a patient receiving cold therapy is improving?

Relief from muscle spasms Cold therapy can provide relief from muscle spasms. Such relief indicates the patient is improving.

Which action would the nurse take when placing noncommercial ice packs on a patient's injured shoulder?

Remove air from the pack before closing. - The nurse would remove the air from the pack before closing.

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound?

Repositioning the patient - Repositioning the patient is a task the UAP can perform for a patient with a wound. Reporting any changes in patient's skin integrity or condition - The UAP can report any changes in the patient's skin condition or integrity to the nurse. Applying a nonsterile dressing for chronic wounds with an established treatment plan - Application of nonsterile dressings for chronic wounds with an established treatment plan is a task the UAP can perform.

Which situations require an incident report?

Respiratory distress caused by ventilator malfunction - An incident report is required for an equipment malfunction that affects patient safety. Nurse slips and falls on a wet floor - Staff injuries require an incident report. Incorrect opioid dosage administration - A medication error requires an incident report.

Which hypothesis would the nurse develop for an immobile patient who has intact skin?

Risk for Impaired Skin Integrity - Because the patient is immobile but still has intact skin, the hypothesis is a Risk for Impaired Skin Integrity.

Which type of fluid would the nurse likely observe if the patient was hemorrhaging?

Sanguineous - Sanguineous fluid is bright red, and it indicates bleeding that is observed in hemorrhaging.

Which patient situation is a medical emergency?

Shock - A patient experiencing shock is a medical emergency because it indicates the patient is hemorrhaging internally or externally.

Which is an accurate representation of all elements contained in "SBAR?"

Situation, Background, Assessment, and Recommendation - SBAR stands for Situation, Background, Assessment, and Recommendation. These are all components of the nursing process and essential for the transference of patient responsibility.

Which piece of equipment would the nurse likely obtain for a patient who has a prescription for therapy that is primarily heat only?

Sitz bath - Sitz baths are used only as heat therapy, and not for cold therapy. A sitz bath is a form of heat therapy in which the pelvic area is soaked for 20 minutes.

Which factors may impact the development of pressure injuries or nonhealing wounds?

Smoking - Smoking can contribute to development of a nonhealing wound by causing vasoconstriction. Diabetes - Diabetes alters circulation of blood, oxygen, and nutrients to skin and body tissues, and it can contribute to nonhealing wounds. Urinary incontinence - Urinary incontinence may cause skin breakdown and lead to the development of pressure injuries. Skin should always be kept clean and dry.

Which classification would the nurse use for staging a pressure injury that has a full-thickness wound and extends into the subcutaneous tissue, but not into the fascia, muscle, or bone?

Stage 3 - Stage 3 pressure injuries are characterized by full-thickness wounds that extend into the subcutaneous tissue, but not into the fascia, muscle, or bone.

Which hand-off processes could reduce the potential of a sentinel event?

Standardization of critical data - Data standardization reduces the potential for misunderstanding the patient's status or condition that could result in a communication error. increased communication between shifts - The ability to increase communication between shifts, especially in a face-to-face format, allows for bilateral communication where questions can be asked and answered to ensure continuity of care. Accurate and up-to-date patient summaries - Accurate and up-to-date patient information and communication is an essential tool to mitigate unexpected occurrences

Which processes occur in the proliferative phase of wound healing?

Stimulation of angiogenesis - Stimulation of angiogenesis occurs in the proliferative phase to provide the new tissue with oxygen and nutrients. Creation of granulation tissue - Creation of granulation tissue occurs in the proliferative phase to fill in the wound with new cells.

Which action would the nurse take for a patient with a hypothesis of Impaired Skin Integrity?

Suggest increasing fluid intake. - The nurse would suggest increasing fluid intake for a patient with Impaired Skin Integrity to keep skin hydrated.

Which statements are accurate about wound classifications based on the depth of the wound?

Superficial and partial-thickness wounds tend to heal quickly. Superficial and partial-thickness wounds tend to heal quickly and, usually, without scarring. Superficial wounds affect only the epidermis. Superficial wounds are defined as wounds that only affect the epidermal layer of skin. Full-thickness wounds can affect all layers of skin and the bone. Full-thickness wounds injure all layers of skin, and they can penetrate bone.

Which classic signs would the nurse observe in a wound that is in the inflammatory phase of healing?

Swelling - Swelling would occur in the inflammatory phase. Erythema - Erythema is a classic sign that occurs in the inflammatory phase of wound healing.

Which multidisciplinary standardized terminology is essential for controlled nursing vocabulary coding?

Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT) - SNOMED CT is a coding system with controlled vocabulary designed to capture information about a patient's history and outcomes.

Which information would the nurse share with a patient about wound healing by tertiary intention?

The wound will be closed later when the infection risk is reduced. Tertiary intention is a type of healing in which the wound is initially left open for a while and then closed when the infection risk is reduced.

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days?

Therapies consistent with guidelines for treatment of wounds - Therapies consistent with guidelines for treatment of wounds and pressure injuries are an appropriate component to include. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) - Recommendations from collaborating health care professionals, such as a WOCN, are appropriate components to include. Agreement of the patient with the treatment plan - The patient should agree with the established treatment plan to encourage compliance, and this agreement would be included. Capability of the patient to purchase supplies for home care as required - Capability of the patient to purchase supplies for home care is an appropriate component of care to include.

Which reasoning explains why a nurse measures wound size during an initial wound assessment?

To help assess progression of wound healing Measuring wound size helps assess the progression of wound healing. As the wound heals, it becomes smaller.

Which rationales explain how an incident report is used for constructive analysis?

To provide a framework for implementing change - An incident report, in a culture of safety, allows for constructive analysis by providing a framework for change implementation. To provide information to guide solutions -An incident report allows for constructive analysis by informing solution development. To disseminate information regarding the incident - An incident report allows for constructive analysis through incident-related information dissemination.

Which description best characterizes the hand-off process?

Transfer and acceptance of patient responsibility - Accurate and complete hand-offs are essential for patient safety and quality of care. A hand-off transfers patient responsibility from one caregiver to another through the presentation of accurate and up-to-date patient information.

Which functions are associated with the skin?

Transmits sensations of pain The skin provides tactile feedback by transmitting sensations of pain, pressure, and temperature extremes. Regulates body temperature The skin regulates body temperature through perspiration. Forms an effective barrier against environmental hazards The skin forms an effective barrier against environmental hazards, including ultraviolet light, chemicals, microbes, and pathogens. Assists with the elimination of toxins and wastes from the body The skin assists with the elimination of toxins and wastes (like ammonia and urea) through sweat.

Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with minimal drainage?

Transparent - The nurse would anticipate caring for transparent dressings, which are appropriate for wounds with minimal or no drainage.

Which actions would the nurse take for a comatose patient who has frequent liquid stools and has a Braden Scale score of 8?

Turn the patient every 2 hours for repositioning. - Turning and repositioning the patient from side to side helps prevent pressure on the skin, so the nurse would implement this action. Pad and protect any bony prominences. - Padding and protecting any bony prominences help avoid pressure on the skin; the nurse would pad and protect bony prominences to avoid pressure injuries. Wash and dry the patient's skin after each liquid stool. - Washing and drying the patient's skin helps keep the skin clean and dry, so the nurse would implement these actions. Moisture and body fluids irritate the skin and cause excoriation. Replace soiled linens. - Replacing soiled linens helps keep the skin clean and dry; thus, the nurse would implement this action. Prolonged contact with moisture and enzymes can lead to excoriation and maceration.

After receiving report, the nurse would delegate which tasks to the unlicensed assistive personnel?

Turning a patient with a pressure injury - The nurse can delegate turning a patient with a pressure injury to the unlicensed assistive personnel. Cleaning an incontinent patient of stool and urine - The nurse can delegate cleaning an incontinent patient of stool and urine to the unlicensed assistive personnel.

Which parameters would the nurse include when charting about a patient's warm compress on the left leg?

Type of therapy The nurse would chart the type of therapy: warm compress. This communicates which treatment was performed. Length of therapy Warm compress treatment length is necessary to chart because the health care provider determines length of heat therapy. Type of drainage The nurse would chart the type of drainage to note changes over time.

Which categories can the nurse use to organize and link the patient's skin integrity cues?

Type of wound Type of wound is a category the nurse can use to link cues for skin integrity and determine the correct hypothesis. Type of wound bed tissue Type of wound bed tissue is a category the nurse can use to link cues for skin integrity and determine the correct hypothesis. Unexpected assessment findings Unexpected assessment findings is a category the nurse can use to link cues for skin integrity and determine the correct hypothesis. Unexpected laboratory findings Unexpected laboratory findings is a category the nurse can use to link cues for skin integrity and determine the correct hypothesis.

Which statement about ultraviolet light is accurate?

Ultraviolet light A (UVA) penetrates the dermis. UVA penetrates the dermis.

Which techniques would the nurse use to troubleshoot issues with patients' dressings?

Use an abdominal binder to help a patient who has an abdominal wound to cough. - An abdominal binder helps secure dressings and drains and provides support when coughing and would be implemented by the nurse. Use Montgomery straps for a patient who needs frequent dressing changes. - Montgomery straps are used for frequent dressing changes to protect the skin from irritation and skin tears; the straps would be used by the nurse. Use a splint to help a patient who has an abdominal incision to deep breathe. - A splint helps provide support to a patient's incision when deep breathing; it would be used by the nurse.

Which action would the nurse take when irrigating a patient's abdominal wound?

Use sterile technique. The nurse would use sterile technique to irrigate a wound to decrease the chance of infection.

Match the nursing action associated with informatics.

Using an electronic health record (EHR) efficiently - Usability Applying an information process to a specific clinical event - Evidence-based practice Learning new computer software - Computer literacy Acquiring skills to evaluate and use information - Health information literacy

Which skill demonstrates information literacy?

Using the electronic health record to extract information from a patient's last visit - The ability to properly use the electronic health record for patient-related information extraction demonstrates information literacy.

Which questions would the nurse ask to determine the authority of online health information?

What are the author's credentials? - The author's credentials are important to determine the authority of an online source. It is important to know that people writing and supporting the online information are qualified members of the health care community. Is the site a personal web page? - Personal web pages are not regulated and may contain opinions that are not supported by medical evidence. Identifying these pages is important to determining the authority of the site. Who is the publisher or sponsor? - Identifying the publisher or sponsor of the website or information helps the user understand the authority of the writer. Publishers or sponsors greatly affect the credibility or bias of the information.

Which questions should be asked to evaluate a website's credibility?

When was the website last updated? - Evaluating website updates enables everyone to assess the currency and credibility of the site. Can similar information be found in other sources? - Verification of information by asking if it is found in other sources helps evaluate the credibility of the site. Who is the intended audience of the website? - Determining the website's purpose helps determine if the site is intended to inform or persuade the audience. For example, a website with an educational goal is generally more forthright with information and, therefore, more credible than a site created to sell a specific product.

Match the criteria for evaluating health care websites to their associated questions to ask.

Who is the intended audience? - Purpose Are the results biased? - Objectivity When was the site created/updated? - Currency Can the information be found in other sources? - Verification

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum?

Wound, ostomy, and continence nurse (WOCN) - A WOCN would be consulted in this situation to ensure proper healing of the pressure injury. Social worker - A social worker would be part of the collaboration team in this situation to ensure the homeless patient has access to community resources and finances. Nutritionist - A nutritionist should be consulted because the patient is thin.

Which nutrients would need to be increased in the diet of a patient with full-thickness burns?

Zinc - Zinc is essential for healing the skin that is burned. Copper - Copper is needed for healing of the skin. Protein - Fibroblasts need protein to make collagen. Vitamin A - Vitamin A would be needed for healing of the burn. Vitamin C - Vitamin C would be needed for collagen formation.