Skin Integrity and Wound Care

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when i reddened area blanches on fingertip touch?

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

Which description best fits that of serous drainage from a wound?

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

Which of the following describes a hydrocolloid dressing?

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

When is an application of a warm compress indicated? (Select all that apply.)

What is the removal of devitalized tissue from a wound called?

Which of the following is NOT an important dimension to consistently measure to determine wound healing?

What does the Braden Scale evaluate?

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?

Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. Mr Post is at risk for developing a pressure ulcer on his coccyx because of:

Which of the following is not a subscale on the Braden scale for predicting pressure ulcer risk?

Which of these patients has a nutritional risk for pressure ulcer development?

Mr. Perkins has a stage II ulcer of his right heel. What would be the most appropriate treatment for this ulcer?

An adolescent who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply.)

A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment findings should the nurse expect? (Select all that apply.)

A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? (Select all that apply.)

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client’s surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? (Select all that apply.)

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin? (Select all that apply.)

What stage would this pressure ulcer be classified as?

What stage would this pressure ulcer be classified as?

What stage would this pressure ulcer be classified as?

What stage would this pressure ulcer be classified as?

What stage would this pressure ulcer be classified as?