The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first?

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Skin Integrity and Wound Care NCLEX Questions Quizlet Questions

Question 1 of 5

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first?

Correct Answer: C

Rationale: Stopping the procedure addresses immediate pain, allowing further assessment.

Question 2 of 5

The nurse caring for a patient who has experienced a laparoscopic appendectomy should expect what type of wound healing when planning care for this patient?

Correct Answer: D

Rationale: Laparoscopic incisions, small and clean, heal by primary intention , per the flashcards, with approximated edges minimizing infection and scarring. Partial-thickness is for shallow loss. Secondary intention suits open wounds. Tertiary intention delays closure. Nurses focus on suture care and infection watch, making this the correct healing type.

Question 3 of 5

A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

Correct Answer: B

Rationale: Pulse oximetry , per the flashcards, assesses oxygen saturation crucial for wound healing, as hypoxia delays repair. Muscular strength aids mobility, not healing directly. Options C and D are missing. Nurses ensure oxygenation (>90%) supports cellular repair, making this the correct data.

Question 4 of 5

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?

Correct Answer: B

Rationale: Air-fluidized beds , per the flashcards, redistribute pressure via immersion, protecting Stage IV grafts. Low-air-loss prevents moisture. Lateral rotation aids lungs. Standard mattresses lack support. This bed optimizes healing, making it the correct choice.

Question 5 of 5

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan?

Correct Answer: C

Rationale: Stage IV ulcers warrant Impaired skin integrity' , per NANDA-I, as the primary issue, per the flashcards. Nutrition is a goal. Mobility and pain may coexist. This drives wound care, making it the correct diagnosis.

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