Skin integrity Wound care ATI questions and study book correct answers highlighted < Tissue Integrity NCLEX Questions with correct answers verified 100

Skin integrity Wound care ATI questions and study book correct answers highlighted &lt; Tissue Integrity NCLEX Questions with correct answers verified 100Skin integrity Wound care ATI questions and study book correct answers highlighted &lt; Tissue Integrity NCLEX Questions with correct answers verified 100 A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes myelitis. Their Hgb is 12 g/dL and BMI is 17.1. This incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? Select all that apply A. Extreme in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care - correct answers-B,c,d A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? Select all that apply A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - correct answers-A,b,c A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information. Which of the following alterations for wound healing by secondary intention? Select all that apply A. Stage 3 pressure injury B. Sutured surgical fracture C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area - correct answers-A,e A client who had abdominal surgery 24 he ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? Select all that apply A. Cover the area with saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abdomen C. Use sterile gauze to apply settle pressure to the exposed tissues D. Position the client supine with the hips and knees bent E. Offer the client a warm beverage (herbal tea) - correct answers-A,d A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? Select all that apply A. Keep the head of the bed elevated 30 degrees B. Massage the clients bony prominences frequently C. Apply cornstarch liberally to the skin after bathing D. Have the client sit in a gel cushion when in a chair E. Reposition the client at least every 3 he while in bed - correct answers-A,d The nurse determines that the patient's wound may be infected. To perform an aerobic wound culture, the nurse should: A. Swab the necrotic tissue area B. Collect the culture before cleansing the wound C. Obtain a culturette tube and you sterile technique D. Place the used swab in a plastic bag and send it to the laboratory - correct answers-C Pressure injures form primarily as a Tissue Integrity NCLEX Questions with correct answers verified 100% The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factors will the nurse assess for that predisposes a patient to pressure ulcer development? A.Decreased level of consciousness B.Adequate dietary intake C. Shortness of breath D. Muscular pain - correct answers-A. Decreased level of consciousness The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer? A.Resistance B.Pressure C.Weight D.Stress - correct answers-B.Pressure Which nursing observation will indicate the patient is at risk for pressure ulcer formation? a. The patient has fecal incontinence. b. The patient ate two thirds of breakfast. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds. - correct answers-A.The patient has fecal incontinence The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record? a. Stage I pressure ulcer b. Healing Stage II pressure ulcer c. Healing Stage III pressure ulcer d. Stage III pressure ulcer - correct answers-C.Healing stage III pressure ulcer The nurse is admitting an older patient form a nursing home. During the assessment, the nurse notes a shallow open reddish,pink, ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? A. Stage I B.Stage II C.Stage III D.Stage IV - correct answers-B.Stage II The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient? A.Disposable measuring tape B.Cotton tipped applicator C.Sterile gloves D.Halogen light - correct answers-D.Halogen light The nurse is caring for a patient with a stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? A.Partial thickness wound repair B.Full thickness wound repair C.Primary intention D.Tertiary intention - correct answers-B.Full thickness wound repair The nurse is caring for a group of patients. WHich patient will the nurse see first? A.A patient with a stage IV pressure ulcer B.A patient with a Braden Scale score of 18 C.A patient with appendicitis using a heating pad D.A patient with an incision that is approximated - correct answers-C.A patient with appendicitis using a heating pad The nurse is caring for a patient who is experiencing a full thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing? A.Eschar B.Slough C.Granulation D.Purulent drainage - correct answers-C.Granulation The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care of plan. A.Partial thickness repair B.Secondary intention C.Tertiary intention D.Primary intention - correct answers-D.Primary intention The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient? A.Partial thickness repair B.Secondary intention C.Tertiary intention D.Primary intention - correct answers-B.Secondary intention A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention? A.Minimal loss of tissue function B.Permanent dark redness at site C.Minimal scar tissue D.Scarring that may be severe - correct answers-D.Scaring that may be severe The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing? A.The site is hurting B.The site approximated C.The site has started to itch D.The site has a mass, bluish in color - correct answers-D.The site has a mass bluish in color A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? A. Protrusion of visceral organs through a wound opening B. Chronic drainage of fluid through the incision site C. Report by patient that something has given way D.Drainage that is odorous and purulent - correct answers-C.Report by patient that something has given way A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? A.Vitamin E B. Potassium C.Albumin D. Sodium - correct answers-C.Albumin A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? A. Muscular strength assessment b. Pulse oximetry assessment C. Sensation assessment D. Sleep assessment - correct answers-B. Pulse oximetry assessment The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? A.Complete the head-to-toe assessment, including treatment, vital signs, and laboratory results B. Notify the health care provider by utilizing situation, background, assessment, and recommendation (SBAR) C. Consult the wound care nur