Factors placing clients at risk for impaired skin integrity -correct answers Factors include
immobility, incontinence, poor nutrition, decreased sensation, chronic illnesses, and aging skin.
Key components of a comprehensive wound assessment -correct answers Location, size, depth,
wound bed appearance, exudate type and amount, surrounding skin condition, pain, and signs
of infection.
Nursing interventions promoting healing and preventing wound infection -correct answers
Proper wound cleansing, maintaining moist wound environment, nutrition support, infection
control, repositioning, and use of support surfaces.
Support surfaces in pressure injury prevention -correct answers They redistribute pressure and
reduce shear, helping to prevent tissue ischemia.
Nurse's role in teaching a family member to change a pressure ulcer dressing -correct answers
Develop a teaching plan, demonstrate and supervise return demonstration, ensure
understanding of aseptic technique, and assess competence.
Local effects of heat therapy on wounds -correct answers Vasodilation, increased blood flow,
reduced muscle tension, and promotion of healing.
Assessment measures predicting risk for pressure injuries -correct answers Mobility status,
nutritional status, moisture exposure, sensory perception, and body fluids.
,Significance of pain in wound assessment -correct answers Pain indicates tissue damage or
infection, requiring appropriate management to promote healing.
Purpose of using the Braden Scale -correct answers To assess risk for pressure injury by
evaluating sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Managing incontinence to prevent skin breakdown -correct answers Use barrier creams,
frequent skin assessments, prompt cleansing after episodes, and moisture-wicking materials.
Nurse's responsibility during wound care implementation -correct answers Follow aseptic
technique, perform dressing changes as ordered, monitor for infection, and educate the
client/family.
Stages of pressure injuries -correct answers Stage I (non-blanchable erythema), Stage II (partial
thickness skin loss), Stage III (full-thickness skin loss), Stage IV (full-thickness tissue loss).
Economic consequences of pressure injuries on healthcare -correct answers Increased
treatment costs, longer hospital stays, and higher morbidity.
Key elements of a wound care plan -correct answers Assessment data, nursing diagnosis,
measurable outcomes, interventions, and evaluation criteria.
Importance of repositioning in pressure injury prevention -correct answers It relieves pressure,
improves circulation, and prevents ischemia.
Clinical judgment in nursing -correct answers The observed outcome of critical thinking and
decision making in nursing practice.
, Clinical reasoning -correct answers By analyzing client data to make informed clinical decisions
and guide interventions.
Five steps of the nursing process -correct answers Assessment, Nursing Diagnosis, Planning,
Implementation, and Evaluation (ADPIE).
Prioritizing problems during care planning -correct answers Using Maslow's hierarchy of needs,
safety concerns, and client stability.
PES format in nursing diagnosis -correct answers Problem, Etiology (related to), and Symptoms
(defining characteristics).
Critical thinking competencies in nursing -correct answers Scientific method, problem solving,
decision making, diagnostic reasoning, and clinical decision making.
Importance of setting measurable client outcomes -correct answers To evaluate progress and
effectiveness of nursing interventions.
Evaluating client outcomes -correct answers By assessing if outcomes were met, revising care
plans, and reflecting on nursing judgments.
Role of reflection in clinical judgment -correct answers It helps nurses learn from experiences
and improve future decision making.
SBAR tool in nursing -correct answers For structured communication with healthcare teams to
promote safe, coordinated care.
Levels of critical thinking -correct answers Basic involves following rules, complex involves
analyzing alternatives, and commitment involves making decisions independently.
immobility, incontinence, poor nutrition, decreased sensation, chronic illnesses, and aging skin.
Key components of a comprehensive wound assessment -correct answers Location, size, depth,
wound bed appearance, exudate type and amount, surrounding skin condition, pain, and signs
of infection.
Nursing interventions promoting healing and preventing wound infection -correct answers
Proper wound cleansing, maintaining moist wound environment, nutrition support, infection
control, repositioning, and use of support surfaces.
Support surfaces in pressure injury prevention -correct answers They redistribute pressure and
reduce shear, helping to prevent tissue ischemia.
Nurse's role in teaching a family member to change a pressure ulcer dressing -correct answers
Develop a teaching plan, demonstrate and supervise return demonstration, ensure
understanding of aseptic technique, and assess competence.
Local effects of heat therapy on wounds -correct answers Vasodilation, increased blood flow,
reduced muscle tension, and promotion of healing.
Assessment measures predicting risk for pressure injuries -correct answers Mobility status,
nutritional status, moisture exposure, sensory perception, and body fluids.
,Significance of pain in wound assessment -correct answers Pain indicates tissue damage or
infection, requiring appropriate management to promote healing.
Purpose of using the Braden Scale -correct answers To assess risk for pressure injury by
evaluating sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Managing incontinence to prevent skin breakdown -correct answers Use barrier creams,
frequent skin assessments, prompt cleansing after episodes, and moisture-wicking materials.
Nurse's responsibility during wound care implementation -correct answers Follow aseptic
technique, perform dressing changes as ordered, monitor for infection, and educate the
client/family.
Stages of pressure injuries -correct answers Stage I (non-blanchable erythema), Stage II (partial
thickness skin loss), Stage III (full-thickness skin loss), Stage IV (full-thickness tissue loss).
Economic consequences of pressure injuries on healthcare -correct answers Increased
treatment costs, longer hospital stays, and higher morbidity.
Key elements of a wound care plan -correct answers Assessment data, nursing diagnosis,
measurable outcomes, interventions, and evaluation criteria.
Importance of repositioning in pressure injury prevention -correct answers It relieves pressure,
improves circulation, and prevents ischemia.
Clinical judgment in nursing -correct answers The observed outcome of critical thinking and
decision making in nursing practice.
, Clinical reasoning -correct answers By analyzing client data to make informed clinical decisions
and guide interventions.
Five steps of the nursing process -correct answers Assessment, Nursing Diagnosis, Planning,
Implementation, and Evaluation (ADPIE).
Prioritizing problems during care planning -correct answers Using Maslow's hierarchy of needs,
safety concerns, and client stability.
PES format in nursing diagnosis -correct answers Problem, Etiology (related to), and Symptoms
(defining characteristics).
Critical thinking competencies in nursing -correct answers Scientific method, problem solving,
decision making, diagnostic reasoning, and clinical decision making.
Importance of setting measurable client outcomes -correct answers To evaluate progress and
effectiveness of nursing interventions.
Evaluating client outcomes -correct answers By assessing if outcomes were met, revising care
plans, and reflecting on nursing judgments.
Role of reflection in clinical judgment -correct answers It helps nurses learn from experiences
and improve future decision making.
SBAR tool in nursing -correct answers For structured communication with healthcare teams to
promote safe, coordinated care.
Levels of critical thinking -correct answers Basic involves following rules, complex involves
analyzing alternatives, and commitment involves making decisions independently.
