SELECT THE RIGHT ANSWER QUES : The nurse is preparing to perform a moist-to-dry dressing change…
SELECT THE RIGHT ANSWER
The nurse is preparing to perform a moist-to-dry dressing change on a patient with a large dehisced surgical wound of the abdomen. The nurse begins to organize the supplies and knows to prioritize which nursing intervention?
a. Gather all the needed dressing and treatment supplies.
b. Protect the patient’s bedding using waterproof pads.
c. Ensure privacy during the dressing change.
d. Administer pain medication before the dressing change.
The nurse is performing skin check rounds on the stroke rehabilitation unit. While assessing a patient’s skin, the nurse notices an unstageable pressure injury on the left heel covered with a layer of dark, dry eschar. Which intervention is the appropriate next action?
a. Obtain an order for enzymatic debridement.
b. Obtain an order for moist-to-dry debridement interventions.
c. Complete a vascular assessment to determine if debridement is appropriate.
d. Document the presence of the wound and notify the practitioner.
A 52-year-old person with diabetes presents for ankle–brachial index (ABI) assessment. The left leg is dusky red and cool to touch while the right leg appears normal. The person has no sensation from the knees and reports no pain. ABI calculation is 1.1 on the left side and 1.3 on the right side. What is the correct interpretation?
a. ABI is normal but clinical indications are inconsistent; further testing is recommended.
b. ABI is low; client should be referred for vascular surgery.
c. ABI is normal; no further action required.
d. ABI is elevated; client should be referred for toe–brachial index.
The patient’s postoperative wound drain was removed yesterday. Today, the nurse notes increased drainage on the dressing, pain at the wound site, and a low-grade fever. What should the nurse conclude from these findings?
a. These signs and symptoms suggest an infection at the wound site.
b. These changes in wound drainage require replacement of the wound drain.
c. These changes indicate a normal postoperative wound healing process.
d. These changes indicate a normal postoperative wound healing process.