Lesson 19 Wound Care

4/29/2020 Lesson 19 - Wound Care: HESI RN FLMIR 1904COHORT
Lesson 19 - Wound Care

Due Apr 29 at 11:59pm Points 24 Questions 24
Available Mar 18 at 12am - Apr 29 at 11:59pm about 1 month Time Limit None
Instructions
This is your Simulation Assignment for today.
Remember to only complete this on the day of simulation and complete by midnight. No copy and paste
from internet. Write answers in your own words.
Attempt History
Attempt Time Score
LATEST Attempt 1 77 minutes 11 out of 24 *
* Some questions not yet graded
Score for this quiz: 11 out of 24 *

Submitted Apr 29 at 9:13am
This attempt took 77 minutes.
Question 1 Not yet graded / 1 pts
Exercise 1 - Writing Activity
This exercise will take approximately 10 minutes to complete.
Exercise 1 - Question 1
List at least three nursing actions that are important when preparing a
patient for a dressing change.
Your Answer:
Review previous wound assessment
https://concorde.instructure.com/courses/18808/quizzes/142984 1/16
Evaluate pain and , if indicted, administer analgesics so peak effects

occur during dressing change
Decribe procedure steps to lesson patient anxiety.
Preparation of a patient for a dressing change should include the

following:
Evaluate pain and, if indicated, administer required analgesics so

that peak effects occur during the dressing change
Describe steps of the procedure to the patient
Assess and recognize signs of healing during removal of the old

dressing
Gathering supplies needed for the dressing change
Answering questions about the procedure
Question 2 1 / 1 pts
True or False: Hydrocolloid dressings support wound healing by debriding

necrotic wounds.
Correct!
True
False
True or False: Hydrogel dressings can absorb large amounts of exudate.
True
Correct!
False
True or False: Before removing a moist-to-dry dressing, you should

moisten the dressing with saline.
True
Correct!
False
True or False: When selecting a dressing, you should choose one that
keeps the surrounding intact skin dry.
ou Answered True
orrect Answer False
When completing the assessment of a pressure ulcer, you note the

presence of yellow exudate. The ulceration extends into the subcutaneous
tissue. Which stage of ulcer does this represent?
Stage I
Stage II
Correct!
Stage III
Stage IV
A patient is planning to increase zinc intake to promote wound healing.

Which of the following foods should be included in the diet to address this
plan?
Eggs
Oranges
Correct!
Broccoli
Fish
Potatoes
A pressure ulcer has the presence of stringy tissue attached to the wound
bed. Which of the following terms may be used to correctly describe this
manifestation?
Eschar
Correct!
Slough
Pus
Granulation tissue
Exercise 2 - Virtual Hospital Activity

Sign in to work at Pacific View Regional Hospital on the Medical-
Surgical Floor for Period of Care 1. (Note: If you are already in the
virtual hospital from a previous exercise, click on Leave the Floor and
then on Restart the Program to get to the sign-in window.)
From the Patient List, select Harry George (Room 401).
Click on Get Report; read the report and then click on Go to Nurses'
Station.
Click on Chart and then on 401.
Click on and then review the Nursing Admission and History and
Physical.
Why has Harry George been admitted to the hospital?
Your Answer:
My foot has been killing me and nothing helps the pain.
Harry George has been admitted to the hospital with osteomyelitis

in the foot.
Listed below are factors that influence wound healing. Which factors apply
to Harry George? Select all that apply.
Correct!
Nutrition
Correct!
Smoking
Correct!
Circulation
Drugs
Obesity
Correct!
Infection
Age
Wound stress
Correct!
Diabetes
Click on Return to Nurses' Station.

Click on 401 at the bottom of the screen.
Read the Initial Observations.
Explain why Harry George’s left foot is elevated.
Your Answer:
Patient’s left foot was elevated with 2 pillows, because the left foot red and
swollen with small amount of serous drainage that is noted on dressing to
ankle.
The skin surrounding the wound is swollen. Elevation of the leg will
improve venous return and thus reduce swelling in the foot.
Click on Patient Care and then on Physical Assessment.

Click on Lower Extremities (yellow buttons) and review each of the
four subcategories (green buttons) for assessment findings.
Based on the description of Harry George’s wound, the type of drainage

present can best be described as:
thick, yellow, or brown.
Correct! clear, watery plasma.
pale, red, watery.
bright red.

Click on History and Physical and review the Social History section.
What factor(s) in Harry George’s social history may be implicated in his

ability to care for his wound? Explain.
Your Answer:
He has been homeless for months and only gets to homeless shelter for
care and meal occasionally. Poor hygiene, nutrition, and lack of medical
supplies can cause infection.
Harry George has evidence of poor hygiene. His self-care

practices suggest he will need instruction that stresses the
relationship between cleanliness of the skin and wound healing. He
has no place to live and therefore has no regular access to running
water. There will be a need either to provide access to an
appropriate resource or to schedule him for regular visits to a
health care center.
Click on and then review the Physician’s Notes.

Click on Consultations and review the Wound Care Team Consult.
The wound care note describes Harry George’s dressing as occlusive.

Which of the following dressings is most likely being used for Harry
George?
Moist-to-dry
Telfa gauze
Correct! Hydrocolloid
Foam dressing
Give a rationale for your answer to the previous question.
Your Answer:
Hydrocolloid dressings are dressing with complex formulation of colloids

and adhesive components. They are adhesive and occlusive. The wound
contact layer of this dressing forms a gel as wound exudate is absorbed
and maintains a moist healing environment.
This dressing is suited to Harry George because it can support

healing in necrotic wounds, the dressing is occlusive, it can absorb
wound moisture, and it is protective and can stay in place several
days.
Exercise 3 - Virtual Hospital Activity
Sign in to work at Pacific View Regional Hospital on the Skilled

Nursing Floor for Period of Care 1. (Note: If you are already in the
virtual hospital from a previous exercise, click on Leave the Floor and
then on Restart the Program to get to the sign-in window.)
From the Patient List, select Goro Oishi (Room 505).
Click on Get Report; review the report and then click on Go to
Nurses' Station.
Click on and then review the Nursing Admission and History and
Physical.
Which of the following risk factors are currently placing Goro Oishi at risk
for developing a pressure ulcer? Select all that apply.
Correct! Impaired sensation
Correct! Impaired mobility
Correct! Altered level of consciousness
Moisture
Using the Braden Scale, determine Goro Oishi's risk for developing
pressure ulcers. Explain the process by which you arrived at your
conclusion and specify the patients Braden Scale score.
Your Answer:
Sensory Perception: Limited ability to most of body surface 1
Moisture: Rarely moist 4
Activity: Patient confined to bed 1
Mobility: Completely immobile 1
Nutrition: Pt is NPO due to coma

1
Friction & Shearing: Problem, requires assistance to move 1
Total: 9
Goro Oishi’s Braden Scale would be 9: sensory perception 1;

moisture 4; activity 1; mobility 1; nutrition 1; friction and shear 1.
What intervention is most likely preventing prolonged exposure of Goro

Oishi’s skin to moisture?
Your Answer:
A condom catheter
Lack of repositioning q 2hr
The placement of the condom catheter. The patient is unconscious

and therefore incontinent of urine. The condom catheter collects
urine, preventing moisture from collecting on bed linen.
Click on Return to Nurses' Station.
Click on 505 at the bottom of the screen.

Review the Initial Observations.
Click on Patient Care and then on Physical Assessment.
Click on Head & Neck and then on Integumentary; then review the
findings. Complete an assessment of the integumentary system by
clicking on each of the remaining six body system categories (yellow
buttons) and clicking on Integumentary within each category.
For which of the locations identified below is Goro Oishi at risk for
developing a pressure ulcer?
Your Answer:
All due to the lack of movement, A-J
He is at risk for pressure ulcers at all of these locations: A, B, C, D,

E, F, G, H, I, and J.
Click on EPR and then on Login.

Select 505 from the Patient drop-down menu and Integumentary from
the Category drop-down menu. Review the data.
Select Hygiene and Comfort from the Category drop-down menu and
review the data.
Goro Oishi’s Braden Scale score indicates that he is at high risk for
developing a pressure ulcer. List at least three interventions for a high-risk
ulcer prevention protocol.
Your Answer:
Topical skin care and incontinence management, Positioning, Support

surfaces.
A high-risk protocol would include each of the following

interventions:
Increase frequency of turning
Supplement turning with additional small position shifts
Apply heel protector
Place a pressure-reducing support surface on bed
Use foam wedges for 30-degree lateral positioning
Manage moisture
Answer the following questions based on your review of Goro Oishi's EPR
data:
Do you believe Goro Oishi is being turned often enough?

At what time is he due to be turned again, according to the current
schedule?
In what position should he next be placed?
What specialty mattress is currently in use?
Your Answer:
1. Yes
2. 0742
3. Right
4. Air
Do you believe Goro Oishi is being turned often enough?: With his risks, Goro
Oishi likely requires turning more often than every 2 hours.
At what time is he due to be turned again, according to the current

schedule?: He should be turned again at 0800 on the current schedule.
In what position should he next be placed?: He should be turned next on his

back.
What specialty mattress is currently in use?: Currently, he is not on a

specialty mattress.
Which of the following are appropriate interventions for the nurse to

perform each time Goro Oishi is turned? Select all that apply.
Correct!
Assess the area on which the patient was previously lying for redness.
Massage any area of redness.
Correct!
Check underlying linen for moisture.
Correct!
Apply additional moisturizer to the skin.
If you were selecting a support surface on which to place Goro Oishi, what
type would you choose? Give a rationale.
Your Answer:
Non-powered; Reduces pressure by lowering mean interface pressure

between patient's tissue and mattress. Pressure redistribution. Air moves
to and from cells as body position changes. Prevention or treatment of
skin breakdown.
You would select a pressure-relieving device. Goro Oishi is being

supported with palliative care. The goal is to keep him comfortable.
For that reason there is no need to go to the expense of a kinetic
therapy bed or air-fluidized bed. He should receive excellent care
by being placed on a low air-loss system or static air-filled overlay.
Click on Exit EPR.

Review the Nurse's Notes.
Goro Oishi is currently receiving IV fluids. What benefit will the ordered
change in nutritional therapy provide for the patient?
Your Answer:
It will aide in wound healing, especially with the protein that he will be
receiving from the enteral nutrition, that will more than likely raise the pre-
albumin levels with this patient.
The change to a tube feeding will increase caloric and protein

intake, designed to place the patient in positive nitrogen balance.
Quiz Score: 11 out of 24

Lesson 19 Wound Care

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4/29/2020 Lesson 19 - Wound Care: HESI RN FLMIR 1904COHORT

Lesson 19 - Wound Care

* Some questions not yet graded

Score for this quiz: 11 out of 24 *

Question 1 Not yet graded / 1 pts

Exercise 1 - Writing Activity

This exercise will take approximately 10 minutes to complete.

Review previous wound assessment

Evaluate pain and , if indicted, administer analgesics so peak effects

Decribe procedure steps to lesson patient anxiety.

Preparation of a patient for a dressing change should include the

Evaluate pain and, if indicated, administer required analgesics so

Describe steps of the procedure to the patient

Assess and recognize signs of healing during removal of the old

Gathering supplies needed for the dressing change

Answering questions about the procedure

True or False: Hydrocolloid dressings support wound healing by debriding

True or False: Hydrogel dressings can absorb large amounts of exudate.

True or False: Before removing a moist-to-dry dressing, you should

orrect Answer False

When completing the assessment of a pressure ulcer, you note the

A patient is planning to increase zinc intake to promote wound healing.

Question 9 Not yet graded / 1 pts

Exercise 2 - Virtual Hospital Activity

This exercise will take approximately 20 minutes to complete.

Why has Harry George been admitted to the hospital?

My foot has been killing me and nothing helps the pain.

Harry George has been admitted to the hospital with osteomyelitis

Question 11 Not yet graded / 1 pts

Click on Return to Nurses' Station.

Explain why Harry George’s left foot is elevated.

Click on Patient Care and then on Physical Assessment.

Based on the description of Harry George’s wound, the type of drainage

thick, yellow, or brown.

Correct! clear, watery plasma.

pale, red, watery.

Question 13 Not yet graded / 1 pts

Click on Chart and then on 401.

What factor(s) in Harry George’s social history may be implicated in his

Harry George has evidence of poor hygiene. His self-care

Click on and then review the Physician’s Notes.

The wound care note describes Harry George’s dressing as occlusive.

Question 15 Not yet graded / 1 pts

Give a rationale for your answer to the previous question.

Hydrocolloid dressings are dressing with complex formulation of colloids

This dressing is suited to Harry George because it can support

Exercise 3 - Virtual Hospital Activity

This exercise will take approximately 45 minutes to complete.

Sign in to work at Pacific View Regional Hospital on the Skilled

Correct! Impaired sensation

Correct! Impaired mobility

Correct! Altered level of consciousness

Question 17 Not yet graded / 1 pts

Sensory Perception: Limited ability to most of body surface 1

Moisture: Rarely moist 4

Activity: Patient confined to bed 1

Mobility: Completely immobile 1

Nutrition: Pt is NPO due to coma

Friction & Shearing: Problem, requires assistance to move 1

Goro Oishi’s Braden Scale would be 9: sensory perception 1;

Question 18 Not yet graded / 1 pts

What intervention is most likely preventing prolonged exposure of Goro

Lack of repositioning q 2hr