Order Skin Integrity And Cound Care

Order Skin Integrity And Wound Care
Order Skin Integrity And Wound Care
1. Thirty-six hours after having surgery, a patient has a
slightly elevated body temperature and generalized
malaise, as well as pain and redness at the surgical site.
Which intervention is most important to include in this
patient’s nursing care plan?
a. Document the findings and continue to monitor the
patient.
b. Administer antipyretics, as ordered.
c. Increase the frequency of assessment to every hour
and notify the patient’s physician.
d. Increase the frequency of wound care and contact
the physician for an antibiotic order.
2. Which term would the nurse use to document wound
drainage that is thick, odorous, and green?
a. Serous
b. Sanguineous
c. Serosanguineous
d. Purulent
3. A patient who has a large abdominal wound
suddenly calls out for help because she feels as
though something is falling out of her incision.
Inspection reveals a gaping open wound with tissue
bulging outward. In which order should the nurse
perform the following interventions? (Arrange from
first to last.)
a. Notify the physician immediately of the situation.
b. Cover the exposed tissue with sterile towels
moistened with sterile NSS
c. Place the patient in the low Fowler’s position
4. A patient, age 16, was in an automobile accident and
received a wound across her nose and cheek. After
surgery to repair the wound, the patient says, “I am so
ugly now.” Based on this statement, what nursing diagnosis would be most appropriate?
a. Pain
b. Impaired Skin Integrity
c. Disturbed Body Image
d. Disturbed Thought Processes
5. A patient is admitted with a nonhealing surgical
wound. Which nursing action is most effective in
preventing a wound infection?
a. Using sterile dressing supplies
b. Suggesting dietary supplements
c. Applying antibiotic ointment
d. Performing careful hand hygiene
6. During a dressing change, inspection of the wound
reveals what appears to be reddish-pink tissue in
the wound. The nurse interprets this as most likely
indicating:
a. A sign of infection
b. Eschar
c. Exudate
d. Granulation tissue
7. The nurse is performing a sterile irrigation of an open
abdominal wound. Which intervention should be done
first?
a. Direct a stream of solution into the wound.
b. Position the patient so the irrigation solution will
flow from clean to dirty.
c. Assess the wound and surrounding tissue.
d. Put on sterile gloves.
8. The nurse is developing a plan of care for an 86-yearold woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s)
indicate a high risk for pressure ulcer development for
this patient? Select all that apply.
a. The patient takes time to think about her responses
to questions.
b. The patient’s age of 86 years.
c. Patient reports inability to control urine.
d. A scheduled hip arthroplasty
e. Lab findings include BUN 12 (elderly normal
8-23 mg/dL) and creatinine 0.9 (adult female
normal 0.61.1 mg/dL).
f. Patient reports increased pain in right hip when
repositioning in bed or chair.
9. The nurse is explaining to a patient the anticipated
effect of the application of cold to an injured area.
What response indicates the patient understands the
explanation?
a. “I can expect to have more discomfort in the area
where the cold is applied.”
b. “I should expect more drainage from the incision
after the ice has been in place.”
c. “I should see less swelling and redness with the cold
treatment.”
d. “My incision may bleed more when the ice is first
applied.”
10. The nurse is providing patient teaching regarding the
use of negative pressure wound therapy. Which explanation provides the most accurate information to the
patient?
a. The therapy is used to collect excess blood loss and
prevent the formation of a scab.
b. The therapy will prevent infection, ensuring the
wound heals with less scar tissue.
c. The therapy provides a moist environment and stimulates blood flow to the wound.
d. The therapy irrigates the wound to keep it free from
debris and excess wound fluid.
11. After an initial assessment, the nurse documents the
presence of a reddened area that has blistered. According to recognized staging systems, as what stage would
this ulcer be classified?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
12. An older confused patient sits and slumps in her chair
most of the day. She is most likely to develop a
pressure ulcer because of what factor?
a. Malnutrition
b. Shearing forces
c. Edema
d. A chronic disease
13. The nurse assesses a stage III pressure ulcer manifested
as:
a. Redness that persists when pressure is relieved
b. An open lesion with full thickness tissue loss and
visible subcutaneous fat
c. A necrotic area extending through the fascia to
bone
d. A reddened area with an abrasion and pain
14. Which action would be a priority in preventing a
patient from developing a pressure ulcer?
a. Using waterproof material on the bed
b. Massaging any reddened area frequently
c. Using an air-inflated ring to relieve pressure on
areas
d. Using a mild cleansing agent when cleansing
the skin
15. In which sequence should the nurse implement the
interventions to clean a surgical wound with dehisced
edges?
a. Clean the wound in full or half circles, beginning in
the center and working toward the outside
b. Moisten sterile gauze or swab with prescribed
cleansing agent
c. Clean to at least 1 inch beyond the end of the new
dressing
d. Explain the procedure to the patient
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