FiltersDone

Question type

Essay

Multiple Choice

Short Answer

True False

Matching

Exam 36: Skin Integrity and Wound Care

Show Answer

Share

---

All types

Filters

Study FlashcardsPractice ExamLearn

Question 1

Multiple Choice

Review LaterAdd Note

Review Later

The nurse is collecting a specimen from an infected wound.From which portion of the wound should the specimen be collected?

A) Clean areas of granulation tissue
B) Exudate in the bottom of the wound
C) A pus-coated area on the side of the wound
D) Intact skin at the edge of the wound

Correct Answer

verified

A

Question 2

Multiple Choice

Review LaterAdd Note

Review Later

The nurse is writing the plan of care for a client who is confined to bed.Which intervention should be included to help reduce the effects of shearing forces on the client's skin?

A) Keep the head of the client's bed at 30 degrees.
B) Coat the client's back and buttocks with baby powder after bathing.
C) Use a turn sheet lifted by two staff members to move the client in bed.
D) Dust the linens with cornstarch each morning to allow for easier movement.

Correct Answer

verified

Show Answer

Question 3

Multiple Choice

Review LaterAdd Note

The client has a documented stage III pressure ulcer on the right hip.What NANDA nursing diagnosis problem statement is most appropriate for use with this client?

The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions.Before using this scale the nurse

A client has a yellow wound with purulent drainage.The nurse identifies what type of wound care as appropriate for this client's wound? (Select all that apply)

The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection.For which category of wound should the receiving nurse plan care for this client?

During morning care,unlicensed assistive personnel observe a client's abdominal wound dressing become saturated with bright red blood.What should unlicensed assistive personnel do?

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months.What does the nurse determine as the significance of the trending of these scores?

The nurse identifies an older client as being at risk for impaired skin integrity.What did the nurse assess in this client? (Select all that apply)

A client has several dark,thick scars on body locations from previous surgeries and injuries.The nurse realizes this occurs during which phase of wound healing?

A client is prescribed steroid medication.When preparing discharge instructions,the nurse should include information about infection control because steroids cause

A client asks why a cold pack has been prescribed for an arm injury.What should the nurse explain to the client? (Select all that apply)

A client has sustained multiple contusions from a motor vehicle accident.What should the nurse do to prepare for this client's care?

On the fourth postoperative day,the client has a sudden coughing episode and tells the nurse that "something popped" in the abdominal incision.Upon inspection,the nurse finds that evisceration has occurred.What nursing action should be taken first?

Multiple severely injured clients have arrived in the emergency department.On rapid assessment,the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage.The client is otherwise stable.What action should the nurse take?

A client's laceration has been closed with tissue adhesive.What instruction should the nurse provide the client about wound healing?

While changing a client's dressing,the nurse notes thick yellow-green drainage on the gauze.How should the nurse document this wound's drainage?

The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter.The tissue around the area is edematous and feels boggy.The edges of the wound cup in toward the center.Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

Upon assessing a pressure ulcer,the nurse notes the presence of red,yellow,and black tissue.Using the RYB color code,which wound care should the nurse plan?

The nurse is preparing to apply a bandage to a client using the spiral reverse turn.For which body parts should the nurse use this technique when bandaging? (Select all that apply)