When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when i reddened area blanches on fingertip touch?
A local skin infection requiring antibiotics
Sensitive skin that requires special bed linen.
A stage III pressure ulcer needing the appropriate dressing
Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
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?
Stage I
Stage II
Stage III
Stage IV
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
Necrotic tissue
Wound drainage
Drainage on the dressing
Wound after it has first been cleaned with normal saline.
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?
Allow the area to be exposed to air until all drainage has stopped.
Place several cold packs over the area, protecting the skin around the wound.
Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.
Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.
Which description best fits that of serous drainage from a wound?
Fresh bleeding
Thick and yellow
Clear, watery plasma
Beige to brown and foul smelling
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?
Binder
Ice bag
Elastic bandage
Absorptive diaper
Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?
Keeping the buttocks exposed to air at all times.
Using a large absorbent diaper, changing when saturated
Using an incontinence cleaner, followed by application of a moisture-barrier ointment
Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel.
Which of the following describes a hydrocolloid dressing?
A seaweed derivative that is highly absorptive
A premoistened gauze placed over a granulating wound
A debriding enzyme that is used to remove necrotic tissue
A dressing that forms a gel that interacts with the wound surface.
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?
Collection of wound drainage
Reduction of abdominal swelling
Reduction of stress on the abdominal incision
Stimulation of peristalsis (return of bowel function) from direct pressure
When is an application of a warm compress indicated? (Select all that apply.)
To relieve edema
For a patient who is shivering
To improve blood flow to an injured part
To protect bony prominences from pressure ulcers
What is the removal of devitalized tissue from a wound called?
Debridement
Pressure reduction
Negative pressure wound therapy
Sanitization
Which of the following is NOT an important dimension to consistently measure to determine wound healing?
Width
Length
Girth
Depth
What does the Braden Scale evaluate?
Skin integrity at bony prominences, including any wounds
Risk factors that place the patient at risk for the skin breakdown
The amount of repositioning that the patient can tolerate
The factors that place the patient at risk for poor healing.
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?
Unstageable
Suspected deep tissue damage
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:
Friction
Maceration
Shearing force
Impaired peripheral circulation
Which of the following is not a subscale on the Braden scale for predicting pressure ulcer risk?
Age
Activity
Moisture
Sensory perception
Which of these patients has a nutritional risk for pressure ulcer development?
Patient A has an albumin level of 3.5.
Patient B has a hemoglobin level within normal limits.
Patient C has a protein intake of 0.5 g/kg/day.
Patient D has a body weight that is 5% great than his ideal weight.
Mr. Perkins has a stage II ulcer of his right heel. What would be the most appropriate treatment for this ulcer?
Apply a heat lamp to the area for 20 minutes
Apply hydrocolloid dressing and change it as necessary.
Apply a calcium alginate dressing and change when strikethrough is noted.
Apply a thick layer of enzymatic ointment to the ulcer and the surrounding skin.
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.)
Extremes in age
Impaired circulation
Impaired/suppressed immune system
Malnutrition
Poor wound care
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.)
Increase in incisional pain
Fever and chills
Reddened wound edges
Increase in serosanguineous drainage
Decrease in thirst
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.)
Stage III pressure ulcer
Sutured surgical incision
Casted bone fracture
Laceration sealed with adhesive
Open burn area
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.)
Cover the area with saline-soaked sterile dressings.
Apply an abdominal binder snugly around the abdomen.
Use sterile gauze to apply gentle pressure to the exposed tissues.
Position the client supine with his hips and knees bent.
Offer the client a warm beverage, such as herbal tea.
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.)
Keep the head of the bed elevated 30 degrees.
Massage the client’s bony prominences frequently.
Apply cornstarch liberally to the skin after bathing.
Have the client sit on a gel cushion when in a chair.
Reposition the client at least every 3 hr while in bed.
What stage would this pressure ulcer be classified as?
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