Chapter 32: skin integrity and wound care.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

A Penrose drain promotes passive drainage into a dressing.

A nurse is caring for a client who has a 6 × 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 most likely to be ordered by the primary care provider?

alginate

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?

Tearing of a structure from its normal position

The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"It provides a way to remove drainage and blood from the surgical wound."

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff 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.

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 skin around the incision.

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation.

A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For what type of injuries would the nurse be alert?

Broken left ankle Bruising Soft tissue damage Concussion Abrasions

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus

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?

Fish

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 a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

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 adheres to the wound bed. Which modification is most appropriate?

Reduce the time interval between dressing changes

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 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?

Stop removing staples and inform the surgeon

he 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 sitting in a chair who slides down

The nurse has delegated applying an elastic bandage with clips to the right knee of a 12-year-old client to the unlicensed assistive personnel (UAP). Which action will the nurse determine the UAP needs additional training?

applies wrap from proximal to distal direction. A roller bander or elastic bandage with clips should be applied from a distal to proximal direction.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

cleanse with a new gauze for each stroke

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?

foul-smelling drainage that is grayish in color.

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.

he registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

Apply saline solution-moistened gauze over the protruding area.

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.

A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product?

The dressing allows oxygen exchange between the wound and environment.

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. Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

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 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

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

corticosteroids

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 necrotic tissue, which must be removed to promote healing."

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

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

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

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?

elevating and supporting the stump

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure?

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.

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.

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

serosanguineous

A nurse is using the RYB wound classification system to document client wounds. Which wound would the nurse document as a Y (yellow) wound?

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.

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.

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?

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.

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

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided.

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

evisceration

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?

secure the drain to the client's gown with a safety pin below the level of the wound.

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

The nurse is caring for a Penrose drain for a client 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, then cuts off the end of the drain with sterile scissors. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

secondary intention

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 works outward from the wound in lines parallel to it.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform?

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes