Nokea
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.
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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.
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 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 who is confined to bed and who has a stage 2 pressure injury is being cared for in the home by family members. To prevent further tissue damage, which of the following actions should the nurse instruct the family members that it is most important?
- A. Change the patient's bedding frequently.
- B. Use a hydrocolloid dressing over the injury.
- C. Record the size and appearance of the pressure injury weekly.
- D. Change the patient's position every 2 hours.
Correct Answer: D
Rationale: The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions also may be included in family teaching, but the most important instruction is to change the patient's position every 2-4 hours.
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.