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WorksheetsChapter 32 skin integrity and wound care
Total questions: 5
Worksheet time: 3mins
Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and:
covering the wound area with sterile towels moistened with sterile 0.9% saline.
closing the wound area with reinforced adhesive skin closures.
pouring sterile hydrogen peroxide into the abdominal cavity and packing it with gauze.
holding the wound together until the health care provider arrives.
When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?
Perform hand hygiene.
Insert a swab into the wound at 90 degrees.
Measure the width of the wound with a disposable ruler.
Assess the condition of the visible wound bed.
What nursing concern is the priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?
altered self-care ability
altered nutrition risk
anxiety
infection risk
A nurse is assessing a client with a stage 4 pressure injury. What assessment of the injury would be expected?
blister formation
full-thickness skin loss
skin pallor
eschar formation
A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?
mixture of serum and red blood cells
large numbers of red blood cells
white blood cells, debris, bacteria
clear, watery blood
