You are admitting a patient and are performing a skin assess…

You are admitting a patient and are performing a skin assessment. Upon assessment, you find a stage III pressure ulcer on the patient’s ischial tuberosity. Identify all priority integumentary nursing assessments:  a. Pain assessmentb. Measurements, including depth, width, and heightc. Characteristics of exudate/ drainaged. Home nutrition regimene. Tissue quality in wound bed

The nurse informs a patient that a wet-to-dry dressing is ap…

The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed? a. Destruction of tissueb. Bleedingc. Mechanical debridementd. Prevention of infection

The nurse notes that the client’s surgical dressing is satur…

The nurse notes that the client’s surgical dressing is saturated and wet with sanguineous drainage one hour post-operatively. The nurse does which of the following? Select All That Apply. a. Notify the MD.b. Reinforce the dressing.c. Connect the drainage system to suction. d. Assess the client’s vital signs.e. Note the color and amount of drainage.