TISSUE INTEGRITY

a. "I'll wear nonsterile gloves"

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? a. "I'll wear nonsterile gloves" b. "I'll use adhesive remover each time" c. "I'll take my pain pill after I change the dressing" d. "I'll fold the dressing with the soiled surface facing outward"

c. Nutrition

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? a. Incontinence b. Mental state c. Nutrition d. General physical condition

a. Hydrocolloid

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressing should the nurse apply to the ulcer? a. Hydrocolloid b. Collagen c. Calcium alginate d. Proteolytic enzyme

d. Proteolytic enzyme

A nurse is caring for a client who has an unstageable pressure ulcer. Which of the following wound dressing should the nurse apply to the ulcer? a. Hydrocolloid b. Collagen c. Calcium alginate d. Proteolytic enzyme

d. Halo of erythema on the surrounding skin

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse reports to the provider? a. Tenderness when touched b. Pink, shiny tissue with a granular appearance c. Serosanguinesous drainage d. Halo of erythema on the surrounding skin

b. Montgomery straps

A nurse is changing the dressings of a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to decrease skin irritation? a. Abdominal binder b. Montgomery straps c. Hypoallergenic tape d. Plastic tape

b. Keeping microorganisms from entering the wound

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? a. Preventing the transfer of microorganisms to the nurse b. Keeping microorganisms from entering the wound c. Applying minimal pressure to the wound d. Keeping excess moisture from entering the wound

a. Vitamin C and zinc

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? a. Vitamin C and zinc b. Vitamin D c. Vitamin K and iron d. Calcium

d. Granulation tissue fills the wound during healing

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieced of information should the nurse include in the teaching? a. The wound edges are well-approximated b. The wound is closed at a later date c. A skin graft is placed over the wound bed d. Granulation tissue fills the wound during healing

d. "I will clip each suture close to the skin and pull it through from the other side"

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? a. "I will use a staple removed and remove each suture individually" b. "Bandage scissors are used to cut the sutures" c. "Tweezers are necessary only for removing retention sutures" d. "I will clip each suture close to the skin and pull it through from the other side"

b. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? a. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage b. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage c. A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguineous drainage d. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

b. Dry, brittle hair c. Edema e. Poor wound healing

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (select all that apply) a. Gingivitis b. Dry, brittle hair c. Edema d. Spoon-shaped nails e. Poor wound healing

c. Calcium alginate

A nurse is caring for a client who has a stage IV pressure ulcer. Which of the following wound dressing should the nurse apply to the ulcer? a. Hydrocolloid b. Collagen c. Calcium alginate d. Proteolytic enzyme

d. Provide a protein intake of 1.5 g/kg of body weight per day

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following action should the nurse include in the plan of care to promote wound healing? a. Limit total caloric intake to 25 kcal/kg of body weight b. Provide an intake of 500 mg/day of vitamin E c. Limit fluid intake to 20 mL/kg of body weight per day d. Provide a protein intake of 1.5 g/kg of body weight per day

b. "I'll wash my hands before I remove the old dressing and again before putting on the new one"

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? a. "I'll wrap the old dressing in a paper bag and put it in the trash" b. "I'll wash my hands before I remove the old dressing and again before putting on the new one" c. "I'll need to take a pain pill 30 minutes before I change the dressing" d. "I'll wear sterile gloves when I apply the new dressing"

a. Don clean gloves to remove the old dressing

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take? a. Don clean gloves to remove the old dressing b. Loosen the dressing by pulling the tape away from the wound c. Remove the entire old dressing at once d. Open sterile supplies after applying sterile gloves