Wound Management (Sherpath) Questions and Answers 100% Pass

Wound Management (Sherpath) Questions and Answers 100% Pass Which patients are at risk for abnormal wound healing? An older adult An older patient is at risk for abnormal wound healing because re-epithelialization is slower as age increases. A patient with AIDS A patient with AIDS is at an increased risk for abnormal wound healing because the immune system is weakened in AIDS. The nurse is caring for a patient with a partial-thickness wound. The nurse understands which tissues are involved? Select all that apply. Dermis A partial-thickness wound involves the dermis. Epidermis The epidermis is involved in a superficial and a partial-thickness wound. A patient arrives at the emergency room after sustaining a cut to the arm a week ago that is "just not healing right." Which local manifestations would the nurse expect to observe if the wound is infected? Redness Redness would be present around the wound if it is infected. Swelling of the arm Swelling is a common symptom of infection and is the result of fluid accumulation as blood rushes to the affected area to bring healing and clotting factors. Inability to move the arm A person with an infected arm wound may be unable to move their arm due to inflammation and pain. A patient is scheduled to undergo a biopsy of a 4-cm deep wound to determine the source of the wound infection. The patient asks the nurse, "Why can't you just collect some of this stuff with a cotton swab?" What is the nurse's best response? "Your wound is deeper and it is best to biopsy the tissue." A biopsy works best to determine the source of infection for deeper wounds. Which wound-related task can the RN delegate to the unlicensed assistive personnel (UAP)? Measure and empty a wound drainage container The UAP is able to measure the volume of fluid in a wound drainage container and empty its contents. The nurse is educating the patient about dietary changes needed to promote wound granulation. Which dietary choices would indicate the patient understands the instruction provided? A ham and cheese sandwich with an orange and milk A ham and cheese sandwich with milk is a food choice that is high in protein. Protein-rich foods promote wound healing. An orange is a good dietary source of vitamin C, which is necessary to promote wound granulation. The wound care nurse is preparing to dress a wound. The nurse notes increased granulation at the site. Which dressing should the nurse prepare to use? Clear plastic dressing An occlusive, clear plastic dressing is used for wounds that are granulating. The nurse performing a focused wound assessment will document which findings? Presence of exudate in the wound base