PCC Skin Integrity

The nurse is assessing the client’s wound and notes that the wound bed shows granulation. What phase of wound healing is described by the nurse’s note?

• Proliferation

• Maturation

• Inflammation

• Hemostasis

A client is post-abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following?

• Additional surgical staples

• Steri-Strips

• Paper Tape

• Abdominal binder

Which of the following clients does the nurse recognize as being at greatest risk for pressure injury?

• A toddler with abrasions to the knees

• A 22 year old with type 1 diabetes

• A 48 year old with quadriplegia

• A 78 year old who uses a cane to ambulate

A patient who experienced traumatic injuries after a motorcycle accident has a wound on his lower extremity that the surgeon reports will be sutured closed after reevaluting in 2 weeks. What form of healing is this?

• Regenerative healing

• Tertiary healing

• Primary healing

• Secondary healing

The nurse developed a plan of care that includes a diagnosis of Impaired Skin Integrity due to a stage 2 pressure injury. Nursing interventions include frequent repositioning and toileting, elevating the patients heels, and q8h skin assessments. A patient outcome goal statement is "wound will remain free of infection." According to the NCSBN Clinical Judgment Model this patient outcome is:

• Recognizing Cues

• Evaluating Outcomes

• Generating Solutions

• Analyzing cues