Josephine Morrow

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.) A. Have you noticed any swelling on your feet, ankles, or fingers? B. What kind of activities cause you to be fatigued? C. Do some areas of your skin seem warmer or colder than others? D. Have you used pads or special pants because you can't control your urine? E. Do you have any sores on your body?

A. Have you noticed any swelling on your feet, ankles, or fingers? Do some areas of your skin seem warmer or colder than others? D. Have you used pads or special pants because you can't control your urine? E. Do you have any sores on your body?

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? A. Pick up the dressing and use the side that did not touch the bed. B. Remove gloves and go to the supply room to obtain more supplies. C. Ask the patient to press the call bell to summon a co-worker to obtain another dressing. D. Reapply the original dressing until a new one can be obtained.

C. Ask the patient to press the call bell to summon a co-worker to obtain another dressing.

The nurse assesses a wound and documents it as stage III. What did the nurse observe when the wound was assessed? Intact skin with non-blanchable redness of a localized area. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. Full-thickness tissue loss, possibly with visible subcutaneous fat. Full-thickness tissue loss with exposed bone, tendon, or muscle.

Full-thickness tissue loss, possibly with visible subcutaneous fat.

The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure? In order to debride the wound, I will use a moderate amount of force to instill the solution. I will make sure the tip of the syringe touches the wound bed while performing the irrigation. 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. I will use a sterile specimen cup to slowly pour irrigation solution over the entire wound bed.

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 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? Tap water Normal saline Isopropyl alcohol Dakin's solution

Normal saline

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 Hypertension Obesity Poor hygiene

Poor hygiene Diabetes mellitus Poor circulation Obesity

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. Maintain strict bed rest. Perform neurovascular checks to look for changes.

Provide meticulous skin care. Perform neurovascular checks to look for changes. Monitor patient for signs of skin breakdown. Assist with range of motion exercises to lower extremities.

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 anti-embolism stockings as soon as you get up in the morning and wear them all day. Sit with your legs in the dependent position so that blood will drain to lower extremities. Keep skin surrounding the wound dry and inspect it at least once a week. Avoid ambulating as this may aggravate your condition.

Put an anti embolism stockings as soon as you get up in the morning and wear them all day.

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? Irrigation helps to sterilize the wound. The application of fluid helps hydrate the surrounding tissue. The procedure helps remove drainage and debris from the wound. The irrigation fluid contains medication for the wound.

The procedure helps remove drainage and debris from the wound.

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 Whole grain bread Green leafy vegetables Baked potato

Baked chicken

The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? A. Albumin B. Pre-albumin C. Calcium D. Iron

Pre-albumin

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 Turgor

Odor Drainage Tunneling Location

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? A. Pale, white toes with decreased sensation. B. Shiny skin with hair loss over legs, feet, and toes. C. Dark discoloration of the skin surrounding the wound site. D. Scaly rash between the toes with itchiness.

C. Dark discoloration of the skin surrounding the wound site.

The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12? Not at risk Low risk Moderate risk High risk

High risk

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

Perulent

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.

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. Hydrocolloid dressings help to maintain a moist wound environment. I can leave this dressing in place for three to seven days. It will help protect the wound from contamination.

The dressing will need to be held in place by surgical tape.