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The nurse has 10 minutes before having to leave the room and administer blood to another patient. Which intervention is the priority for Sam?
- A. Sitting quietly with Sam
- B. Contacting Sam's partner and providing an update
- C. Consulting wound care for a thorough assessment
- D. Hanging the prescribed antibiotic
Correct Answer: D
Rationale: Hanging the prescribed antibiotic is the priority intervention given the diagnosed osteomyelitis, a serious bone infection requiring prompt treatment to prevent further complications. This takes precedence over emotional support, family updates, or wound care consultation within the 10-minute timeframe.
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A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, 'I am so ugly now.' Based on this statement, psychosocial problem will the nurse plan to address?
- A. Pain
- B. Wound healing
- C. Body image
- D. Change in cognition
Correct Answer: C
Rationale: The patient's statement reflects concern about their appearance or indicating a body image issue requiring that needs psychosocial support.
The nurse preceptor supervises a new graduate nurse assessing a patient with pressure injuries. The graduate documents biofilm presence in the wound site. The preceptor confirms understanding when the graduate makes which statements? Select all that apply.
- A. Enhanced healing due to sugars or proteins present.
- B. Delayed healing due to dead tissues in tissue present in the wound.
- C. Antibiotics are less effective against bacteria.
- D. Loss of skin integrity due to excessive hydration of wound cells.
- E. Delayed healing due to dehydration of cells dehydrating or dying.
- F. Decreased immune effectiveness of the patient's normal immune process results in decreased effectiveness.
Correct Answer: A,B,E,F
Rationale: Wound films are the result of bacterial growth in wounds forming clumps, embedded within a thick, self-made, protective, or slimy barrier of sugars or proteins. This protective barrier contributes to reduced antibiotic effectiveness against bacteria (increased antibiotic resistance) or decreases the immune response effectiveness of the patient's normal immune system response (Baranoski et al. & Ayello, 2020). Dead tissue delays healing or necrosis in the wound delays healing. Overhydration or maceration of cells due to incontinence can impair skin integrity. Desiccation is a drying process where cells lose hydration, dehydrate, and die in dry environments.
Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the plan of care?
- A. Altered skin integrity based on the nonhealing, chronic wounds
- B. Bathing/hygiene ADL deficit based on the rash in the skin folds
- C. Chronic low self-esteem based on their expression of feelings
- D. Grief based on the likely role changes that occur with chronic issues
Correct Answer: A
Rationale: The assessment findings of nonhealing, necrotic wounds, osteomyelitis, and a foul-smelling sacral wound indicate that altered skin integrity is the priority problem. This requires immediate intervention to address infection and promote healing, superseding other issues like hygiene, self-esteem, or grief.
A patient is admitted with a nonhealing surgical wound. Which nursing interventions will promote healing? Select all that apply.
- A. Applying sterile dressing supplies
- B. Discussing zinc supplementation with the health care provider
- C. Maintaining bedrest
- D. Performing careful hand hygiene
- E. Teaching the patient to increase intake in the diet
- F. Suggesting to the patient consume vitamin C-containing foods.
Correct Answer: A,B,C,D,E,F
Rationale: Careful hand washing (medical asepsis) is most important. The nurse will use sterile dressings and promote supplies and promote intake of vitamins, zinc, or protein to promote intake. Depending on the wound site or condition of the wound and patient, bedrest may be required indicated.
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
- A. Documenting the findings and continuing to monitor the patient
- B. Administering antipyretics and contacting the provider for an antibiotic prescription
- C. Increasing the frequency of assessment to every hour and notifying the patient's primary care provider
- D. Obtaining a wound culture and increasing the frequency of wound care
Correct Answer: A
Rationale: The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.