Nur 360 Wk 1

A patient is seen in the wound clinic for a pressure ulcer on his left leg. There is full-thickness tissue loss with the bone exposed. The nurse would correctly document this wound as being in which stage?

• I

• II

• III

• IV

A patient is seen in the wound clinic for a pressure ulcer on his left leg. There is full-thickness tissue loss with the bone exposed. The nurse would correctly document this wound as being in which stage?

• Apply liberally to prescribed area

• Absorbtion is enhanced when skin is dry

• Local side effects may include skin atrophy and thinning

• Absorption is decreased when covered with an occlusive dressing

What changes in the older adult best describe why the aging process increases risk for impairment in skin integrity?

• Epidermal cells thicken

• Dermal thickness increases

• Decreased elastin, collagen, and fat

• Maceration

A patient diagnosed with a stasis ulcer has been hospitalized on the unit. The nurse has orders to change the dressing and provide wound care. Which activity should the nurse perform first?

• Wash hands thoroughly

• Assess the drainage on the dressing

• Slowly remove the old dressing

• Put on latex gloves

The nurse is doing a shift assessment on several patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new reddened rash on the patient's chest. The patient should be asked what priority question regarding the presence of a reddened rash?

• Is the rash worse during certain seasons?

• Are you allergic to any food or medications?

• What is your occupation?

• Is there any loss of sensation?