The nurse recognizes that what factor does not put a patient at risk for pressure injury development?
altered mental status
loss of appetite
advanced age
weightlifting
3.
Maceration can be defined as
a loss of superficial layers of the skin.
tissue that has been softened by prolonged wetting or soaking.
tissue that has been hardened by pressure.
tissue that has development of slough.
4.
The nurse is assessing a patient with a deep red area of intact skin that does not blanch. As what stage of pressure injury is this classified?
stage I injury
deep tissue injury
unstageable injury
stage II injury
5.
The nurse is educating a new graduate nurse on pressure injuries and knows that the new graduate nurse understands the teaching when they say what?
“The difference in stage III and IV pressure injuries is the visibility of fascia, tendon, ligament, muscle, cartilage, and bone.”
“Slough and eschar are present at every stage.”
“If the area blanches, it is stage I.”
“A diabetic ulcer is also called a deep-tissue pressure injury.”
6.
Identify the type of exudate from the wound shown.
(credit: “Selfinjury” by “Sumasla”/Wikimedia Commons, Public Domain)
sanguineous
purulent
foul purulent
serous
7.
A patient is being assessed for risk for surgical complication using the SSERA model. The duration of the surgery is expected to be 180 minutes. The nurse recognizes that this surgical length automatically makes the patient what level of risk?
low risk
no risk
high risk
moderate risk
8.
Identify the Wagner Ulcer Classification of the wound shown.
(credit: “Gangrene Foot 01”, by “آرمین”/Wikimedia Commons, Public Domain)
grade 1
grade 2
grade 4
grade 5
9.
When the skin surrounding the wound is spongy and saturated, how should it be described?
edematous
boggy
attached
macerated
10.
What phase of the healing process do leukocytes move into the interstitial space to ingest bacteria and cellular debris?
hemostasis
inflammatory phase
proliferation phase
maturation phase
11.
The nurse is explaining complications associated with wound healing to a new patient at the clinic. How should the nurse describe maceration?
occurs when hydration leads to cell death
occurs when there is trauma the wound
occurs when there is swelling that interrupts blood flow
occurs where the cells are overhydrated leading to skin softening and breakdown
12.
What nursing intervention is appropriate when performing a dressing change?
administering pain medication prior to wound care when the patient states that wound care is painful
telling the patient that they just need to look at the wound
explaining to the patient that the smell from the wound is not that bad
encouraging the patient that they do not have to make any changes in their activities of daily living
13.
What type of debridement promotes the body’s own defense mechanisms?
enzymatic debridement
mechanical debridement
autolytic debridement
wet-to-dry debridement
14.
A patient comes into the emergency room with a burn on their forearm from boiling water. It is red, painful, and blistered. The nurse correctly identifies this as what type of burn?
first degree
second degree
third degree
fourth degree
15.
A farmer comes into the emergency room after being exposed to chemicals while fertilizing their crops. The nurse correctly recognizes what to be true about this type of burn?
The tissue injury ceased after the chemicals were removed.
The injury will require surgical treatment.
The chemicals may continue to impact the tissues after decontamination.
The nurse needs to look for an entry and exit point.
16.
A patient is admitted to the burn unit after a severe burn. They weigh 143 lb (65 kg) and have a TBSA of 25 percent. Using the Parkland burn formula, how much fluid should the nurse expect the patient to receive over twenty-four hours?
6,500 mL
8,300 mL
3,500 mL
12,000 mL
17.
The nurse expects the physician to order a consultation with what type of provider to prevent contractures in a patient with severe burns?
This book may not be used in the training of large language models or otherwise be ingested into large language models or generative AI offerings without OpenStax's permission.
