Exam 67: Tissue Integrity

The nurse has completed the Braden Risk Assessment Scale on a client who has been diagnosed with a pelvic fracture and has not been able to get out of bed for the last 6 days. This morning the client's score is 10, so the nurse will institute which measures that will help prevent further skin injury? Select all that apply.

The nurse is caring for a client with a large venous injury that has just begun to show signs of healing. The nurse contacts the healthcare provider and asks for a change from the chemical method of debridement for which reason?

The nurse is preparing to change the dressing of a client who had abdominal surgery 3 days ago. The nurse notes that the incision has purulent drainage and appears very puffy. The client states that the pain level has increased from a 3 to a 7 in the last 24 hours. Which is the nurse's next action in regard to this client's wound?

The nurse is preparing to change a dry dressing of a surgical wound and will use which technique to ensure that the wound stays clean during the procedure?