Exam 38: Providing Wound Care and Treating Pressure Ulcers

The nurse explains to the patient that the foot will be submerged in warm water for a maximum of ______ minutes.

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:

The nurse irrigating an infected wound of the hand would: (Prioritize the steps. Separate the letters by a comma and a space as follows: A, B, C, D, E, F, G.) A) Open sterile irrigation basin and solution. B) Don sterile gloves to apply dressing. C) Pour irrigating solution in basin. D) Irrigate keeping the syringe tip 1 inch from the wound surface. E) Document procedure. F) Pat wound dry and redress. G) Place pad under the infected hand.

The nurse clarifies that the first stage of wound healing is:

Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal. The nurse would change the dressing procedure in order to use:

The nurse places Dakin solution in a wound to accomplish chemical ___________.

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

The nurse gives an example of a wound that heals by second (secondary) intention as a:

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

A patient is due for a wound dressing change for a horizontal lower abdominal incision. In which direction should the nurse pull to remove the tape from the old dressing?

A nurse caring for a patient with a Stage I pressure ulcer would most appropriately select:

The nurse recognizes that of the drugs a patient is currently taking, several contribute to delayed healing, such as: (Select all that apply.)

The nurse is aware that the only necrotic wound for which debridement is not recommended is a pressure ulcer located on the:

A nurse removing wound staples would engage the staple puller and squeeze the handles completely and:

The nurse changing a patient's surgical dressing will: (Prioritize the steps. Separate the letters by a comma and a space as follows: A, B, C, D, E, F, G.) A) Apply new dressing. B) Remove old dressing. C) Gather supplies. D) Wash hands. E) Don clean gloves. F) Document findings. G) Apply sterile gloves.

A nurse is ambulating a patient in the hall a few days after abdominal surgery and the patient says, "I think something just let go." The initial intervention by the nurse should be to:

The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to: