Wounds Lab 5

Professor Johanna Ramirez

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Slides (36)

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A nurse assesses a client’s heel area and notes a Stage I pressure injury. Which action is most appropriate?

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A nurse is assessing a client’s sacral area. Which finding is most consistent with a Stage I pressure injury?

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A nurse is preparing to perform a sterile dressing change on a client’s surgical incision. Which action demonstrates correct sterile technique?

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Which type of pain is the hardest to treat?

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A nurse is setting up a sterile field for a wound dressing change. Which action would contaminate the sterile field?

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A nurse is preparing a client’s skin for a central line dressing change using aseptic technique. After cleansing with chlorhexidine using back-and-forth strokes, the nurse notices the client begins coughing toward the sterile field. Which action should the nurse take FIRST?

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A client has a shallow, open wound on the heel with a pink-red wound bed and no slough present. The nurse identifies this as:

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The nurse observes a pressure injury on the coccyx with visible subcutaneous fat, yellow slough covering less than 25% of the wound bed, and no exposed bone or muscle. What is the stage?

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A nurse is caring for a client and when she turns them in her assessment she finds this but how does she chart this finding?

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Before the nurse performs wound care on a stage 3 wound she prepares morphine to administer. What key assessments are needed when giving morphine? Select all that apply.

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A client is scheduled for surgery. Which preoperative assessment finding should the nurse report to the provider immediately?

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A nurse reinforces teaching about incentive spirometer use before surgery. Which client statement indicates understanding?

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A client is 1 hour postoperative after abdominal surgery. Which finding requires immediate intervention?

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A nurse is caring for a postoperative client who is immobile. Which nursing action best reduces the risk of deep vein thrombosis (DVT)?

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A client reports severe pain rated 9/10. What is the nurse’s FIRST action?

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BONUS: You are taking care of a client with a severe and painful acute kidney injury which pain med is a danger to your client? Vitals Stable

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A nurse is caring for a patient with a Stage 4 pressure injury on the sacrum. Which intervention is most appropriate for promoting healing of this wound?

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What foods are best for stage 3 and deeper wounds ? Select all that apply.

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