Exam 67: Tissue Integrity

The home health nurse is making the first visit to a client who will continue to need sterile dressing changes after abdominal surgery. In assessing the home environment, which must be considered when performing the home dressing change?

The nurse has just removed sutures on a client and has completed teaching the client about care of the wound at home. Which statement by the client indicates that the client understands the instructions given?

The nurse is preparing to remove sutures from a client who sustained a long, deep laceration after a motor vehicle accident and will use what technique to maintain wound stability?

The nurse is completing a skin assessment at the beginning of the shift and will pay particular attention to which areas of the body that are most prone to skin breakdown? Select all that apply.

The nurse is caring for a client who is at high risk for pressure injury formation because of which factors? Select all that apply.

The nurse is using wet-to-dry dressing changes to assist in debridement of an open abdominal wound and knows that which step must be performed to ensure that the newly granulated tissue in the wound will not be injured during the dressing changes?

The nurse is caring for a client who sustained second-degree burns to both feet. The healthcare provider has ordered debridement of necrotic tissue by mechanical means. The nurse will use which debridement technique that would be the BEST method to complete this task?

A client is slated to begin negative-pressure wound therapy tomorrow and the nurse is reinforcing the teaching about this therapy. Which statement by the client requires further teaching by the nurse?

While making rounds, the charge nurse observes a staff nurse cleaning a surgical wound and notes that the staff nurse has cleaned the wound from the top to the bottom of the wound. Which action should the charge nurse take in this situation?

The nurse is preparing to remove staples from a woman who had a cesarean section 6 days ago and will use which forms of personal protective equipment when performing this task?

The nurse is caring for 4 clients with wounds and would ask that which client be evaluated further for negative-pressure wound therapy?

The nurse is preparing to change the dressing and clean the wound of a client who had hip replacement surgery one day ago. The nurse plans to use which solution for the most effective cleaning of the wound?

The wound care nurse has been asked by the healthcare provider to begin negative-pressure wound therapy on a client. Upon assessment of the wound, the nurse notes that the wound still requires a great deal of debridement. Which should the nurse do in this situation?

The nurse is caring for four clients who have had surgery and knows that which client would benefit the most from the application of a spiral elastic bandage?

The nurse is caring for an older adult client who was admitted to the hospital after having a stroke. The client was in extremely critical condition on admission to the emergency department and a Braden Risk Assessment Scale was not completed. On the client's fifth day of hospitalization, the nurse notes that the client has developed a stage one pressure injury on the elbow of the side affected by the stroke. Which is the implication of this situation in relation to reimbursement for care of the pressure injury?

The nurse is observing a second nurse who is changing a dressing. While observing the procedure, which would cause the nurse to stop the second nurse and take over the procedure?

The nurse has applied an occlusive dressing to a stage 1 pressure injury and knows that this type of dressing assists in debridement of the wound in which way?

Place the steps for changing a sterile surgical dressing in the appropriate order.

The nurse is caring for a client who is receiving negative-pressure wound therapy for an infected leg wound and is aware that the dressing on this wound must be changed how often?

The healthcare provider has ordered an elastic bandage to be applied to a wound on a client's femur. The nurse will begin to apply the bandage at which point on the client's leg?