N5451 Skills Lab Module 9. Skin Integrity and Wound Care Exam Questions With All Correct Answers Verified Answers 2025 Marking Scheme New Update

N5451 Skills Lab Module 9. Skin Integrity and Wound Care Exam Questions With All Correct Answers Verified Answers 2025 Marking Scheme New Update The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure? - Answer- The client's comfort and effectiveness of pain medication The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? - Answer- Raise the bed to elbow height. After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the: - Answer- top to the bottom using a new gauze for each wipe. The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? - Answer- Pat the wound dry with a sterile gauze sponge. The nurse assesses the surgical dressing of a client who has just arrived from the post anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse? - Answer- Reinforce the dressing and assess site frequently The nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation? - Answer- Assess for pain, shortness of breath, and abdominal pressure. When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication? - Answer- Dehiscence. The nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation? - Answer- Use small amounts of sterile saline to help loosen and remove the dressing. The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse? - Answer- Replace the dressing with a larger one. The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention? - Answer- Use Montgomery straps instead of adhesive tape to hold the dressing in place. The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound? - Answer- From the upper end of the wound to the lower end When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure? - Answer- Date and reuse leftover irrigation solution within 24 hours. The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution? - Answer- Sterile basin When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe? - Answer- Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound? - Answer- When the solution from the wound flows out clear The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding? - Answer- Stage 1 pressure injury When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? - Answer- Deep tissue injury Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options. - Answer- Put on clean gloves. Remove old dressing. Assess the wound bed. Open dressing materials. Irrigate the wound bed. Time and date the dressing. Which client is a greatest risk of developing a pressure injury? - Answer- 47 year old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness