Download SKIN INTEGRITY WOUND CARE ATI QUESTIONS AND ANSWERS and more Exams Nursing in PDF only on Docsity! SKIN INTEGRITY WOUND CARE ATI QUESTIONS AND STUDY BOOK A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes myelitis. Their Hgb is 12 g/dL and BMI is 17.1. This incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? Select all that apply A. Extreme in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care - correct answer B,c,d A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? Select all that apply A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - correct answer A,b,c A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information. Which of the following alterations for wound healing by secondary intention? Select all that apply A. Stage 3 pressure injury B. Sutured surgical fracture C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area - correct answer A,e A client who had abdominal surgery 24 he ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? Select all that apply A. Cover the area with saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abdomen C. Use sterile gauze to apply settle pressure to the exposed tissues D. Position the client supine with the hips and knees bent E. Offer the client a warm beverage (herbal tea) - correct answer A,d A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? Select all that apply A. Keep the head of the bed elevated 30 degrees B. Massage the clients bony prominences frequently C. Apply cornstarch liberally to the skin after bathing D. Have the client sit in a gel cushion when in a chair E. Reposition the client at least every 3 he while in bed - correct answer A,d The nurse determines that the patient's wound may be infected. To perform an aerobic wound culture, the nurse should:
