Nurs 204 - Exam #2 (With 100% accurate answers)

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? a. A local skin infection requiring antibiotics b. Sensitive skin that requires special bed linen c. A stage III pressure ulcer needing the appropriate dressing d. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode correct answers d. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I 2. Category/stage II 3. Category/stage III 4. Category/stage IV a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid. correct answers 1a, 2d, 3b, 4c When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? a. Necrotic tissue b. Wound drainage c. Wound circumference d. Cleansed wound correct answers d. Cleansed wound After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (select all that apply) a. Notify the surgeon