Chapter 32 Prep U

The nurse is caring for an older adult client in a long-term care facility. Shat nurse action is important to maintain skin integrity?

Clean perineal area daily but do not bathe full body on a daily basis

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?

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

A nurse is caring for a client who has a 6-cm × 8-cm wound caused by 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 dressing does the nurse anticipate is best to be ordered by the primary care provider?

Alginate

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them?

Apply moist saline compresses to loosen crusts before attempting to remove the staples.

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?

Elevate and support the stump.

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?

Elevate and support the stump.

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

Figure of eight turn

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order.

Hemostasis Inflammatory Proliferation Maturation

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?

Period during which the wound undergoes changes and maturation

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? 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.

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?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

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

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 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?

Stop removing the staples and inform the surgeon

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate reaction?

Stop the sitz bath, call for help, and help the client to the toilet to sit down

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury 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.

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

Mechanical debridement

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

Second degree or partial thickness

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?

Tegaderm