Chapter 32 Skin Integrity and Wound Care Prep U

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed

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?

use pillows to maintain a side-lying position as needed

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

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?"

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

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."

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."

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 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 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."

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."

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 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 assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply.

- 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

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 which type(s) of injury would the nurse be alert? Select all that apply.

- broken left ankle - abrasions - soft tissue damage - concussion - bruising

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply.

- the edges of a healing surgical wound appear clean and well approximated with a crust along the edges - a wound that does not feel hot and tender upon palpation - a wound that forms exudate due to the inflammatory response

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

- use whirlpool treatments, if prescribed, until the injury is considered clean - keep the injury tissue moist and the surrounding skin dry - use a dressing that absorbs exudate but maintains a moist healing environment

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

- warm hand - fingers with quick capillary refill - no finger numberless or tingling

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.

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.

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 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 I pressure injury

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

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

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

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 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 bestaction by the nurse at this time?

Discontinue the therapy and assess the client.

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?

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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 that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound?

proliferation phase

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 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

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 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.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

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 sitting in a chair who slides down

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 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

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 postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence

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

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 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

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

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 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 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

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

hydrocolloid

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

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client?

monitor intake and output

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 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

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

stage II

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

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

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?

transparent