Chapter 31: Skin Integrity and Wound Care prepU, Fundamental of Nursing Chapter 31 Skin Integrity and Wound Care Prepu

The nurse is performing pressure ulcer assessment for patients in a hospital setting. Which patient would the nurse consider to be at greatest risk for developing a pressure ulcer?

A critical care patient

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure?

Clean the wound from the top to the bottom, and center to outside.

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

Decubitus ulcer

45s 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

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

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?

Depth

A nurse is obtaining a wound culture from a sacral pressure ulcer. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse?

Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab.

When performing a dressing change, the home care nurse notes that base of the client's leg wound is red and bleeds easily. Which of the following is the appropriate action by the nurse?

Document the findings.

The nurse is discussing care of a client's wound that has nonviable tissue in the base with the wound care nurse. The wound care nurse recommends that the nurse utilizes a dressing that would promote autolytic debridement of the wound. Which of the following dressings should the nurse select?

Hydrocolloid

A physician orders a wound irrigation to apply an antiseptic to a client's wound. The nurse will follow which guideline for performing this procedure?

If the wound is closed, clean technique may be used instead of sterile technique.

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.

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Penrose drain

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

Stage III.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury?

Stage IV

A nurse is caring for a client who has an avulsion of her left thumb. Which of the following descriptions should the nurse understand as being the definition of avulsion?

Tearing of a structure from its normal position

The nurse is caring for a Penrose drain for a patient post abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion and cuts off the end of the drain with sterile scissors.

A nurse is caring for a client with a nonhealing stage IV pressure ulcer. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?

Undermining

A nurse is caring for a client with a nonhealing stage IV pressure ulcer. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. Which of the following is the correct term for this condition?

Undermining

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 of the following actions should the nurse perform to prevent a pressure ulcer?

Use pillows to maintain a side lying position as needed.

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 ulcer?

Use pillows to maintain a side-lying position as needed.

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Which of the following is the correct order of steps the nurse should perform during this dressing change?

Use sterile gloves Cut the foam to the shape and measurement of the wound Place the drape to cover the wound and an additional 3-5 cm Cut a 2-cm hole in the drape Apply a vacuum device to wound Ensure that negative pressure has been achieved

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

A nurse is caring for a client who had an appendectomy and has been readmitted for wound care. The incision has been opened by the primary care provider to allow for drainage. The wound is draining copious amounts of yellow exudate. Which of the following types of dressing should the nurse understand is appropriate for this wound? Select all that apply.

• Alginates • Antimicrobials • Composites

The nurse is assessing the wounds of patients. Which patients would the nurse place at risk for delayed wound healing? (Select all that apply.)

• An older adult who is bed-ridden. • A patient with a peripheral vascular disorder • A patient who is obese • A patient who is taking corticosteroid drugs

A nurse is caring for a client on a medical surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which of the following actions by the nurse are appropriate in this situation? Select all that apply.

• Cover wound with a gauze moistened with normal saline • Place client in low Fowler's position • Use sterile techniques

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy for piles. Which of the following interventions should the nurse follow to apply the T-binder? Select all that apply.

• Fasten the crossbar around the waist • Pass the tails through the client's legs • Pin the tails to the belt of the T-binder

The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

Assess the wound for active bleeding.

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment?

"Do not douche 24-48 hours before the procedure."

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The oncoming nurse receives in report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

A client's risk for the development of a pressure ulcer is most likely due to which lab result?

Albumin 2.5 mg/dL

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse to select to promote wound healing?

Fish

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?

Impaired tissue integrity

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 of the following actions should the nurse perform in obtaining a wound culture?

Keep the swab and inside of the culture tube sterile.

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 dead or infected tissue to promote wound healing

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the patient's chance of skin breakdown?

Reposition the patient on a regular basis.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage?

Serosanguineous

A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which of the following drainage types should the nurse document?

Serosanguineous

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?

Soak in a warm bath for drainage.

The nurse is caring for a patient who has a pressure ulcer on his back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair.

A student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as unstageable. Which of the following wound descriptions should the student nurse expect to assess?

The wound is 3 cm x 5 cm with yellow tissue covering the entire wound.

A student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 cm × 5 cm with yellow tissue covering the entire wound.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

A woman fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. The client has a(an):

fistula.

When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force.

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 will put a layer of cloth between my skin and the ice pack."

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which of the following statements indicates that the client understands?

"I will squeeze the chamber and apply the cap to maintain negative pressure."

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include?

"It is important to keep your sutured incision clean."

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include?

"Very little scar tissue will form."

You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate?

"Wounds heal better when a moist wound bed is maintained."

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate?

"You will likely experience periods of increased skin outbreaks and periods of remissions."

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."

An older adult client is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply.

-"Eat nourishing foods after surgery to promote healing." -"Monitor your moods after surgery. Depression after surgery is not normal." - "It may take you longer to heal than someone younger." -"Wound healing can take longer if you have been exposed often to the sun."

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.)

-A wound that requires wound cleaning and irrigation. -A wound that is characterized by oozing from the tissue covering the wound. -A wound with drainage that is a beige color.

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer?

65-year-old incontinent client with a hip fracture on bed rest

The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces?

A patient sitting in a chair who slides down

The nurse is preparing to measure the depth of a client's tunneled wound. Which of the following implements should the nurse use to measure the depth accurately?

A sterile, flexible applicator moistened with saline

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

A transparent film

A nurse is caring for a client who has a 6-cm × 8-cm wound that was received in a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which of the following dressings does the nurse anticipate is best to be ordered by the primary care provider?

Alginate

You are caring for a patient who has a heavy exudating wound that needs autolytic debridement. Which of the following wound dressings/products is most appropriate to use on the wound?

An alginate dressing, such as AlgiCell

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

The nurse would recognize which of the following clients as being particularly susceptible to impaired wound healing?

An obese woman with a history of type 1 diabetes

A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development?

Braden scale

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?

Depth.

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 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

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

A nurse is providing wound care for a client who has a pressure ulcer on the right buttock. Which of the following is the correct order of nursing interventions the nurse should perform during this dressing change?

Give pain medication Use nonsterile gloves Remove old dressing Apply sterile gloves Cleanse the wound with normal saline Apply wound covering

A nurse assessing the wound healing of a patient, documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

Primary intention

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care the nurse notes the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize with this client's wound?

Proliferation Phase

A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain?

Provides drainage for bile

A nurse assesses an area of pale white skin over a patient's coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Recognize that this is ischemia, followed by reactive hyperemia.

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:

Second degree or partial thickness

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which of the following types of wound repair would the nurse expect with this wound?

Secondary intention

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document?

Serosanguineous

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

Stage II

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

Stage II

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which of the following stages should the nurse assign to this client's wound?

Stage III

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Support the client from sliding in bed.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is applying a heating pad to a patient experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition?

There is an accidental separation of the wound.

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 of the following responses by the nurse is most appropriate?

Your wound will heal slowly as granulation tissue forms and fills the wound."

A female patient who is being treated for self- inflicted wounds tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk?

Total lymphocyte count of 1,500/mm3

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

Transparent

A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon

True

A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon.

True

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True.

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage?

Under the client

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces?

a client sitting in a chair who slides down

What is the most accurate definition of a wound?

a disruption in normal skin and tissue integrity

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

A client has developed blisters around the tape that secures the dressing. The nurse should:

apply the dressing with a binder.

A client has developed blisters around the tape that secures the dressing. What nursing action would be appropriate to prevent further damage to the tissues?

apply the dressing with a binder.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

contusion

A skin infection caused by beta-hemolytic streptococci common in children is:

impetigo.

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?

incision

In the older adult client, wrinkling is related to:

loss of elasticity.

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention.

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 dead or infected tissue to promote wound healing

A nurse is caring for a client who has recently undergone hernial surgery. The nurse knows that which of the following are possible causes of complications with regard to surgical wounds? Select all that apply.

• Insufficient protein and vitamin C intake • Weak tissue and muscular support due to obesity • Distension of the abdomen from accumulated intestinal gas

Which teaching points would the nurse use to explain the development of pressure ulcers to patients and how to prevent them? (Select all that apply.)

• "Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." • "The skin can tolerate considerable pressure without cell death, but for short periods only." • "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation."

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.)

• 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

Which interventions might a nurse be expected to perform when providing competent care for a patient with a draining wound? (Select all that apply.)

• Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. • Change the dressing midway between meals. • Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound.

A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which of the following interventions should the nurse include in the plan to prevent the development of pressure ulcers? Select all that apply.

• Provide incontinent care every 2 hours and as needed • Turn client every 2 hours while client in bed • Encourage client to take fluids every 2 hours

Which nursing interventions reflect the accurate use of heat or cold during wound care? (Select all that apply.)

• The nurse makes more frequent checks of the skin of an older adult using a heating pad. • The nurse fills an ice bag with small pieces of ice to about two-thirds full. • The nurse covers a cold pack with a cotton sleeve to keep it in a cold pack with a cotton sleeve to keep it in place on an arm.

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? (Select all that apply.)

• Use whirlpool treatments, if ordered, until the ulcer is considered clean. • Keep the ulcer tissue moist and the surrounding skin dry. • Use a dressing that absorbs exudate but maintains a moist healing environment.

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel.

The healthcare provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

Assess the wound for active bleeding.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.