Nokea
The charge nurse observes a new graduate performing a dressing change on a patient with a stage 2 left heel pressure injury. Which of the following actions by the new graduate indicates a need for further education about pressure injury care?
- A. Uses a hydrocolloid dressing (DuoDerm) to cover the injury.
- B. Inserts a sterile cotton-tipped applicator into the pressure injury.
- C. Irrigates the pressure injury with a 30-ml syringe using sterile saline.
- D. Cleans the injury with a sterile dressing soaked in half-strength hydrogen peroxide.
Correct Answer: D
Rationale: Pressure injuries should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.
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The nurse is caring for a patient with a systemic bacterial infection who has 'goose pimples,' feels cold, and rigors. At this stage of the febrile response, which of the following assessments should the nurse monitor?
- A. Skin flushing
- B. Muscle cramps
- C. Rising body temperature
- D. Decreasing blood pressure
Correct Answer: C
Rationale: The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with rising temperatures.
A patient is admitted to the hospital with a pressure injury on the left buttock. The nurse notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure injury wound stages should the nurse document?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: A stage 3 pressure injury has full-thickness skin damage and extends into the subcutaneous tissue. A stage 1 pressure injury has intact skin with some observable damage such as redness or a boggy feel. Stage 2 pressure injuries have partial-thickness skin loss. Stage 4 pressure injuries have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
The nurse is planning care for a patient and is preparing to complete a wet-to-dry dressing. Which of the following wound descriptions is appropriate for using this type of dressing?
- A. Pressure injury with pink granulation tissue
- B. Surgical incision with pink, approximated edges
- C. Full-thickness burn filled with dry, black material
- D. Wound with purulent drainage and dry brown areas
Correct Answer: D
Rationale: Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.
The nurse is assessing a patient the morning of the first postoperative day and notes redness and warmth around the incision. Which of the following actions should the nurse implement?
- A. Obtain wound cultures.
- B. Document the assessment.
- C. Notify the health care provider.
- D. Assess the wound every 2 hours.
Correct Answer: B
Rationale: The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention; the nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.
The nurse is caring for an adult patient with stage 3 pressure injuries on both heels who has been in hospital for 6 days. Which of the following timeframes for wound assessment is accurate when a patient is in the acute care setting?
- A. Every 4 hours
- B. Every 6 hours
- C. Every 12 hours
- D. Every 24 hours
Correct Answer: D
Rationale: In acute care, the patient should be reassessed every 24 hours. In long-term care, a resident should be reassessed weekly for the first 4 weeks after admission and at least monthly or every 3 months thereafter.