CH 32 - Wound Care
During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? Blue-grey Yellow White Red
Red
A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Puncture of the skin Tearing of a structure from its normal position Tearing of the skin and tissue with some type of instrument; tissue not aligned Cutting with a sharp instrument with wound edges in close approximation with correct alignment
Tearing of a structure from its normal position Explanation: An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.
A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: infection. herniation. evisceration. dehiscence.
dehiscence. Explanation: Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? improving the client's hydration preventing the client from sliding in bed pulling the client up from under the arms lubricating the area with skin oil
preventing the client from sliding in bed
The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? adhesive strips with eyelets hydrocolloid transparent gauze
transparent
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? "The surgeon will leave your wound open intentionally for a period of time." "This is a complex reparative process." "Very little scar tissue will form." "The margins of your wound are not in direct contact."
"Very little scar tissue will form." Explanation: Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? FLACC scale Morse scale Glasgow scale Braden scale
Braden scale Explanation: The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glasgow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls.
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? Stage I Stage IV Stage III Stage II
Stage II
A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Apply adhesive wound closure strips after each staple is removed. Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision. Stop removing staples and inform the surgeon
Stop removing staples and inform the surgeon Explanation: If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.
An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: lanugo. prickly heat. acne vulgaris. milia.
milia. Explanation: Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.
A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? Tunneling Size Direction Depth
Depth Explanation: When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To turn the head away from the area whenever coughing To splint the area when engaging in activity To remain in bed for the next 4 hours To ambulate using a cane or walker
To splint the area when engaging in activity Explanation: To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.
A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: an allergic reaction to medications. an allergic reaction to detergent. a rash related to a yeast infection. a rash related to immobility.
a rash related to a yeast infection. Explanation: Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.
Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.
Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps.
The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Desiccation Necrosis Evisceration Maceration
Desiccation
What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen? Risk for Infection related to wound Impaired Skin Integrity related to open wound Pain related to wound sustained by knife Knowledge Deficit regarding wound care related to laceration
Impaired Skin Integrity related to open wound Explanation: Impaired skin integrity best describes the minor laceration. While the other diagnoses, Pain, Knowledge Deficit, and Risk for Infection, are all possible as a result of the laceration, there is no indication in the scenario that they are the case.
A skin infection caused by beta-hemolytic streptococci common in children is: herpes. impetigo. scabies. acne vulgaris.
Impetigo, which usually is caused by beta-hemolytic streptococci, is the most common bacterial skin infection.
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a large wound with considerable tissue loss allowed to heal naturally a surgical incision with sutured approximated edges a wound left open for several days to allow edema to subside a wound healing naturally that becomes infected.
a surgical incision with sutured approximated edges
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? "I can let this stay on my ankle an hour at a time." "I will put a layer of cloth between my skin and the ice pack." "I should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy."
"I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.
A client birthed twins via cesarean and is learning to care for her incision. Which teaching will the nurse include? "Reinforced adhesive skin closures can be peeled off after 48 hours." "It is important to keep your sutured incision clean." "You will have staples in place for several weeks." "You only need a binder to hold your incision together."
"It is important to keep your sutured incision clean."
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?
"Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.
A nurse is using the RYB wound classification system to document client wounds. Which wound would the nurse document as a Y (yellow) wound? Select all that apply. A wound that reflects the color of normal granulation tissue A wound that is covered with thick eschar A wound that is characterized by oozing from the tissue covering the wound A wound that requires wound cleaning and irrigation A wound with drainage that is a beige color A wound that is treated by using sharp, mechanical, or chemical debridement
A wound that is characterized by oozing from the tissue covering the wound A wound with drainage that is a beige color A wound that requires wound cleaning and irrigation
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? As a stage III pressure injury As a stage II pressure injury As a stage I pressure injury As a stage IV pressure injury
As a stage I pressure injury Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV.
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? Dehiscence of the wound Herniation of the wound Infection of the wound Evisceration of the viscera
Dehiscence of the wound
The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. Draw the shape of the wound with a description. Measure the wound's length and width. Chart tunneling by using a quadrant approach to describe the location. Use a dry sterile applicator at a 90-degree angle to measure depth. Assess color, drainage, presence of pain, or complications.
Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications. Explanation:
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? Banana Pasta salad Green beans Fish
Fish To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.
Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? Local capillary pressure must be lower than external pressure. Arteries and veins must be patent and functioning well. The heart must be able to pump adequately. The volume of circulating blood must be sufficient.
Local capillary pressure must be lower than external pressure. Explanation: Local capillary pressure must be higher than external pressure for adequate skin perfusion.
A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Carefully pick the crusts off the sutures with the forceps before removing them. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Do not attempt to remove the sutures because the wound needs more time to heal.
Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.
The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client who lifts himself up on the elbows a client who must remain on the back for long periods of time a client who lies on wrinkled sheets a client sitting in a chair who slides down
a client sitting in a chair who slides down
A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: to provide drainage for bile. to divert drainage to the peritoneal cavity. to provide a sinus tract for drainage. to decrease dead space by decreasing drainage.
to provide drainage for bile. Explanation: A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.
A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? In children younger than 2 years, the skin is thicker and stronger than in adults. A child's skin becomes less resistant to injury and infection as the child grows. An individual's skin changes little over the life span. An infant's skin and mucous membranes are easily injured and at risk for infection.
An infant's skin and mucous membranes are easily injured and at risk for infection.
The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage? recurrent bandaging circular turn only figure-of-eight turn spiral turn
figure-of-eight turn Explanation: To keep a dressing on the ankle in place, the nurse would use a figure-of-eight turn. It is effective for use around joints. The circular turn is used primarily to anchor a bandage. The circular turn starts a spiral turn, a figure-of-eight turn, and a recurrent bandage. The spiral turn is useful for the wrist, fingers, and trunk. A recurrent bandage is used for fingers, the head, and residual limbs after amputation.
The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood? gauze adhesive strips with eyelets transparent hydrocolloid
gauze Explanation: Gauze dressings absorb blood or drainage. Transparent dressings are used to protect intravenous insertion sites. Hydrocolloid dressings are used to used keep a wound moist. Adhesive strips with eyelets are used to secure a gauze dressing that needs frequent changing.
The nurse is working with a group of clients. Which clients are at risk for a skin alteration? Select all that apply. the client who has paralysis and is unable to move in bed, turned by the nurse every 2 hours the client who is a roofer and spends a lot of time outdoors participating in sports the client with newly diagnosed diabetes who requires management education for the disease the client who has experienced vomiting and diarrhea for several days with a loss of 12 lb (5.4 kg) in weight the client who experienced numbness in the right arm that has resolved after several hours
the client who is a roofer and spends a lot of time outdoors participating in sports the client who has experienced vomiting and diarrhea for several days with a loss of 12 lb (5.4 kg) in weight the client who has paralysis and is unable to move in bed, turned by the nurse every 2 hours the client with newly diagnosed diabetes who requires management education for the disease Explanation: The clients at risk for skin alterations are the roofer, the one experiencing fluid disturbances, the client who is paralyzed, and the client who has diabetes. The client who is a roofer and spends a lot of time outdoors has prolonged exposure to the sun and is at risk for skin cancer. The client experiencing vomiting and diarrhea with weight loss is dehydrated. The skin loses elasticity and is prone to breakdown. The client who is paralyzed has reduced sensation and is at risk for pressure injuries due to immobility and friction caused by the lifting and turning by others. The client who has diabetes is at risk for problems related to the disease (nerve damage, poor perfusion) and must be taught how to properly care for himself. The client who had numbness that has resolved is the least at risk; sensation has returned for this client.
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? Document the pain and vital signs. Assess the client's wound and vital signs. Administer the prescribed analgesic. Notify the health care provider of the pain.
Assess the client's wound and vital signs. Explanation: First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.
While walking in the woods, an 8-year-old child trips and a stick cuts the right leg with partial-thickness involvement. What would the camp nurse observe and document about the child's wound? The wound is caused accidentally, and the dermis, sweat glands, and hair follicles are not present. The wound was purposely created from impact of the fall, and all or a portion of the dermis is intact. The wound is caused accidentally, and all or a portion of the dermis is intact. The wound was intentional due to fall, and the dermis, sweat glands, and hair follicles are not present.
The wound is caused accidentally, and all or a portion of the dermis is intact. Explanation: The child sustained an unintentional, partial-thickness wound. An unintentional wound is an accidental wound. An intentional wound is one created for a purpose, like a surgical wound. A partial-thickness wound is characterized by all or a portion of the dermis remaining intact. A full-thickness wound is characterized by severing of the entire dermis, sweat glands, and hair follicles.
Which is not considered a skin appendage? Eccrine sweat glands Sebaceous gland Hair Connective tissue
Connective tissue
The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. a 10-year-old client with a surgical incision a client who eats a diet high in vitamins A and C an older adult who is confined to bed a client who is taking corticosteroid drugs a client who is obese a client with a peripheral vascular disorder
an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drugs
The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? wrapping distally to proximally elevating and supporting the stump exerting equal, but not excessive, tension with each turn of the bandage keeping the bandage free of gaps between turn
elevating and supporting the stump Explanation: The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? Utilize the culture swab to obtain cultures from multiple sites. Stroke the culture swab on surrounding skin first. Cleanse the wound after obtaining the wound culture. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
Keep the swab and the inside of the culture tube sterile prior to collecting the culture. Explanation: The swab and the inside of the culture tube should be kept sterile prior to the procedure. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? The nurse uses friction when cleaning the wound to loosen dead cells. The nurse works outward from the wound in lines parallel to it. The nurse swabs the wound from the bottom to the top. The nurse swabs the wound with povidone-iodine to fight infection in the wound.
The nurse works outward from the wound in lines parallel to it. Explanation: A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.
A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands? "I will alternate between positive and negative pressure every 2 hours." "I will squeeze the chamber and apply the cap to maintain negative pressure." "I will apply a dressing at the end of the drain to catch any drainage." "I will check and empty the drain every 6 hours."
"I will squeeze the chamber and apply the cap to maintain negative pressure." Explanation: The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain has gauze at the end of the drain to catch drainage.
A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply. "Increased appetite will provide better nutrition to help with healing." "Depression after surgery is normal; this will not affect healing processes." "Consider having a home health aide to assist with bathing and personal care." "Older adults with lots of sun exposure may experience delayed healing." "It may take longer for an older adult to heal."
"It may take longer for an older adult to heal." "Consider having a home health aide to assist with bathing and personal care." "Older adults with lots of sun exposure may experience delayed healing."
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing." "This is normal tissue."
"That is necrotic tissue, which must be removed to promote healing." Explanation: Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."
"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.
A client has undergone an open surgical procedure. Which teaching provided by the nurse accurately reflects what the client should expect during the remodeling period? "Blood vessels will constrict to control blood loss." "The wound will contract and scarring will shrink." "Granulation tissue will start to form." "Neutrophils and monocytes will migrate to the site of your incision."
"The wound will contract and scarring will shrink." Explanation: Constriction of blood vessels and appearance of polymorphonuclear leukocytes take place during the inflammation period. Granulation tissue forms during the proliferation period. The surgical wound contracts and scarring shrinks during the remodeling period.
The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? spiral-reverse turn spica turn figure-of-eight turn circular turn
A figure-of-eight turn is used for joints like the elbows and knees. The other answers are incorrect.
The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? Apply a skin protectant to the incision site. Apply a sterile gauze sponge over the incision site. Apply a transparent dressing over the incision site. Apply a skin protectant to the skin around the incision.
Apply a skin protectant to the skin around the incision. Explanation: Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied.
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Use clean technique to clean the wound. Clean the wound from the top to the bottom and from the center to outside. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. Clean the wound in a circular pattern, beginning on the perimeter of the wound.
Clean the wound in a circular pattern, beginning on the perimeter of the wound. Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? potassium supplements laxatives antihypertensive drugs corticosteroids
Corticosteroids Explanation: Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? Discontinue the therapy and assess the client. Document the findings in the client's medical record. Notify the health care provider of the findings. Gently rub and massage the area to warm it up.
Discontinue the therapy and assess the client.
A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client? Placing the client in the supine position with a pillow under the knees Placing the client in a side-lying position with a pillow between the lower legs Placing the client in a wheelchair with the back of the feet resting against the heel loops Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs
Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs
A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document? Staging of the surgical wound Cardiac and respiratory function Presence of abnormalities that would impede healing Length, width, and depth of the wound
Presence of abnormalities that would impede healing Explanation: An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. The nurse should make sure the client is assessed for the presence of abnormalities that would impede healing, such as signs and symptoms of infection, poor circulation below the surgical sight, adequate nutrition, and medications the client may be taking that interfere with healing. The size of the surgical wound would not include depth because of the presence of staples. Cardiac and respiratory assessment would not be the focus for a client after surgical knee replacement, unless the client reported concerns in those areas. Staging is only done on pressure injury
A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. Tap the outside of the culture tube with the swab before placing it in the tube. Use the same swab for both wound sites. Press and rotate the swab several times over the wound surfaces. Touch the swab to the intact skin at the wound edges. Insert a swab into the wound. Place the swab in the culture tube when done.
Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done. Correct response: Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done.
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain.
Rotate the swab several times over the wound surface to obtain an adequate specimen. Explanation: The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.
The nurse would recognize which client as being particularly susceptible to impaired wound healing? a man with a sedentary lifestyle and a long history of cigarette smoking a client whose breast reconstruction surgery required numerous incisions an obese woman with a history of type 1 diabetes A client who is NPO (nothing by mouth) following bowel surgery
an obese woman with a history of type 1 diabetes Explanation: Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.
The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. The nurse packs the wound cavity tightly with dressing material. The nurse uses wet-to-dry dressings continuously. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.
The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. Explanation: A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.
A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention? Use clean technique instead of sterile technique if the wound is closed. If new bleeding is noted, continue irrigation cautiously and then notify the health care provider. Apply petroleum jelly to the periwound skin to protect it from the irrigation solution. Stop irrigating when the solution from the wound turns light pink.
Use clean technique instead of sterile technique if the wound is closed. Clean technique can be used on a closed wound. When the solution from the wound turns clear, the irrigation should be discontinued. If bleeding is noted that was not previously there, the nurse should stop the irrigation and notify the health care provider. There is no need to apply petroleum jelly to the periwound skin.
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? a small plastic ruler an otic curette a sterile tongue blade lubricated with water soluble gel a sterile, flexible applicator moistened with saline
a sterile, flexible applicator moistened with saline
A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? assessing for impaired blood flow to the area of evisceration. applying sterile dressings with normal saline over the protruding organs and tissue monitoring for pallor and mottled appearance of the wound contacting the surgeon
applying sterile dressings with normal saline over the protruding organs and tissue Explanation: The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.
A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood foul-smelling drainage that is grayish in color copious drainage that is blood-tinged
foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing. Reference:
A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn? moist with blisters, which may be pink, red, pale ivory, or light yellow-brown from brown or black to cherry red or pearly white; bullae may be present dry and leathery pinkish or red with no blistering
moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Partial-thickness (second-degree) burns are moderate to deep burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Superficial (first-degree) burns may be pinkish or red with no blistering. Full-thickness (third-degree) burns vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and has adhered to the wound bed. Which revision to the nursing care plan is most appropriate? discontinuing application of saline-moistened packing and applying a hydrocolloid dressing instead ensuring that the packing material is completely saturated when placed in the wound using less packing material reducing the interval between dressing changes
reducing the interval between dressing changes Explanation: Reducing the interval between dressing changes allows the dressing change to be performed without causing pain and promotes secondary intention. If the interval time between dressing changes is reduced, other interventions do not need modification or revision because these are more likely to be effective if the dressing is changed more frequently. If the dressing becomes dry, the more pain the client experiences and the more likely damage to the newly formed epithelial and granulating tissue becomes. The packing material should be completely saturated when placed in the wound. Using less packing material impairs secondary intention. A hydrocolloid dressing is not indicated.
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? removing excess drainage and wet tissue to prevent maceration of surrounding skin removing dead or infected tissue to promote wound healing removing purulent drainage from the wound bed in order to accurately assess it stimulating the wound bed to promote the growth of granulation tissue
removing dead or infected tissue to promote wound healing Explanation: Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.
What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? Tape the drain to the dressing material securely below the level of the wound. Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. Secure the drain to the client's gown with a safety pin below the level of the wound. Apply an abdominal binder over the entire wound and drain to support the site.
secure the drain to the client's gown with a safety pin below the level of the wound. Explanation: To ensure there is not any tension on the tubing of a Jackson-Pratt drain, the nurse should secure the drain to the client's gown with a safety pin below the level of the wound. Taping the drain or applying an abdominal binder will keep the bulb compressed and hinder the suction action of the drain. The drain should not be allowed to hang freely because this causes tension on the drain site.
When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk? ischemia necrosis of tissue friction shearing force
shearing force Explanation: A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.
The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care? applying an ice pack to relieve pain cleansing the labia with scented soap soaking in a warm bath for drainage exposing the area to a heat lamp
soaking in a warm bath for drainage Explanation: Heat promotes vasodilation, allowing the consolidation of pus in infected areas. Scented products may contain chemicals that promote irritation of the infected area and have no curative benefits to this particular client. Cold application will result in vasoconstriction and will not promote healing.
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? provide incontinent care every 4 hours as needed place a foot board on the bed use pillows to maintain a side-lying position as needed elevate the head of the bed 90 degrees
use pillows to maintain a side-lying position as needed Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.
