Question : The nurse is caring for a client who has an open surgical wound : 2135503

6. The nurse is caring for a client who has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. Which of the following terms should the nurse use to document these findings?

a. Red wound

b. Yellow wound

c. Full-thickness wound

d. Stage III pressure wound

7. Which of the following nursing actions is most likely to detect early signs of infection in a client who is taking immunosuppressive medications?

a. Monitor white blood cell count.

b. Check the skin for areas of redness.

c. Check the temperature every 2 hours.

d. Ask about fatigue or feelings of malaise.

8. The nurse is planning care for a client and is preparing to complete a wet-to-dry dressing. Which of the following wound descriptions is appropriate for this type of dressing?

a. Pressure injury with pink granulation tissue

b. Surgical incision with pink, approximated edges

c. Full-thickness burn filled with dry, black material

d. Wound with purulent drainage and dry brown areas

9. A client is admitted to the hospital with a pressure injury on the left buttock. The nurse notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure injury wound stages should the nurse document?

a. 1

b. 2

c. 3

d. 4

10. A client who is confined to bed and who has a stage 2 pressure injury is being cared for in the home by family members. To prevent further tissue damage, which of the following actions should the nurse instruct the family members that it is most important?

a. Change the client’s bedding frequently.

b. Use a hydrocolloid dressing over the injury.

c. Record the size and appearance of the injury weekly.

d. Change the client’s position every 2 hours.