The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

Presence of exudate

A number of sutures

Approximation of edges

Time of last antibiotic

Color of the wound bed

Answer and Explanation

Correct Answer : A,C,E

a. Presence of exudate: The presence and amount of exudate can indicate the severity of the infection and the eﬀectiveness of treatment.

c. Approximation of edges: This refers to how well the edges of the wound are coming together and healing, which is important in evaluating the progress of healing.

e. Color of wound bed: The color of the wound bed can also indicate the severity of infection and the eﬀectiveness of treatment.

Therefore, the correct answers are a, c, and e.

The number of sutures and the time of the last antibiotic are important information for the nurse to know, but they do not need to be included in the documentation of the wound assessment and dressing change.

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Correct Answer is C

Explanation

The client's statement of avoiding people because of having scabies and difficulty walking indicates that the client may be experiencing social isolation and loneliness. Loneliness is a significant concern for clients as it can lead to depression, anxiety, and other negative health outcomes. The other options, such as the potential for falls, injury, and self-neglect, may also be concerns for the client but are not indicated as the greatest concern in this scenario based on the information provided. Therefore, the nurse should document the client's greatest concern as the potential for loneliness.

A. Keep the area open to air B. Cleanse with hydrogen peroxide daily C. Apply hydrocortisone cream to the area D. Keep the suture area covered with gauze

Correct Answer is D

Explanation

After an incisional biopsy of a skin lesion, the client should be instructed to keep the suture area covered with gauze to protect it from irritation and infection. The area should be kept clean and dry, but cleansing with hydrogen peroxide is not necessary and may actually delay healing. The use of hydrocortisone cream is not recommended as it may interfere with wound healing. The area should not be left open to air as this may increase the risk of infection. The client should also be instructed to avoid strenuous activity and lifting heavy objects until the site has fully healed.

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The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

Correct Answer is C

Explanation

The nurse provides care for a client having an incisional biopsy of a skin lesion. Which teaching about the care of the site does the nurse provide to the client?

Correct Answer is D

Explanation

A client receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?

The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)

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The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

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