Chapter 33: Skin integrity and Wound Care

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a) A wound healing naturally that becomes infected. b) A surgical incision with sutured approximated edges c) A wound left open for several days to allow edema to subside d) A large wound with considerable tissue loss allowed to heal naturally

b) A surgical incision with sutured approximated edges

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? a) Infection of the wound b) Evisceration of the viscera c) Dehiscence of the wound d) Herniation of the wound

c) Dehiscence of the wound

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 assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. - Hang the bag of tepid to warm water at the client's chest height on an IV pole - Ensure that the call bell is within reach - Insert tubing into the infusion port of the sitz bath - Fill the bowl of the sitz bath about halfway full with tepid to warm water - Have the client soak for about 50 to 60 minutes - Slowly unclamp the tubing and allow the sitz bath to fill

- Ensure that the call bell is within reach - Insert tubing into the infusion port of the sitz bath - Fill the bowl of the sitz bath about halfway full with tepid to warm water - Slowly unclamp the tubing and allow the sitz bath to fill

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 - Decreased radial pulse - Fingers with quick capillary refill - Cyanosis - No finger numbness or tingling

- Warm hand - Fingers with quick capillary refill - No finger numbness or tingling

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? a) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." b) "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." c) "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." d) "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider."

a) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

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 to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site? a) A transparent film b) A gauze dressing premedicated with antibiotics c) A dressing with a nonadherent coating d) A gauze dressing precut halfway to fit around the IV line

a) A transparent film

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? a) An infant's skin and mucous membranes are easily injured and at risk for infection b) In children younger than 2 years, the skin is thicker and stronger than in adults c) An individual's skin changes little over the life span d) A child's skin becomes less resistant to injury and infection as the child grows

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

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? a) Applying sterile dressings with normal saline over the protruding organs and tissue b) Monitoring for pallor and mottled appearance of the wound c) Assessing for impaired blood flow to the area of evisceration d) Contacting the surgeon

a) Applying sterile dressings with normal saline over the protruding organs and tissue

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? a) Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures b) Carefully pick the crusts off the sutures with the forceps before removing them c) Do not attempt to remove the sutures because the wound needs more time to heal d) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them

a) Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures

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? a) Use pillows to maintain a side-lying position as needed b) Place a foot board on the bed c) Provide incontinent care every 4 hours as needed d) Elevate the head of the bed 90 degrees

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

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? a) "As soon as the infection clears, your surgeon will staple the wound closed." b) "Your wound will heal slowly as granulation tissue forms and fills the wound." c) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." d) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal."

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

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? a) Banana b) Fish c) Green beans d) Pasta salad

b) Fish

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? a) "That is called undermining, a type of tissue erosion." b) "That is old clotted blood underneath the wound" c) "That is necrotic tissue, which must be removed to promote healing." d) "This is normal tissue."

c) "That is necrotic tissue, which must be removed to promote healing."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? a) "The margins of your wound are not in direct contact." b) "The surgeon will leave your wound open intentionally for a period of time." c) "Very little scar tissue will form." d) "This is a complex reparative process."

c) "Very little scar tissue will form."

The nurse would recognize which client as being particularly susceptible to impaired wound healing? a) A client who is NPO (nothing by mouth) following bowel surgery b) A man with a sedentary lifestyle and a long history of cigarette smoking c) An obese woman with a history of type 1 diabetes d) A client whose breast reconstruction surgery required numerous incisions

c) An obese woman with a history of type 1 diabetes

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? a) Administer the prescribed analgesic b) Document the pain and vital signs c) Assess the client's wound and vital signs d) Notify the health care provider of the pain

c) Assess the client's wound and vital signs

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? a) Gently rub and massage the area to warm it up b) Notify the health care provider of the findings c) Document the findings in the client's medical record d) Discontinue the therapy and assess the client

d) Discontinue the therapy and assess the client

The nurse is performing an assessment of a client's full thickness pressure injury to the coccyx. The nurse observes that the wound bed is black and will consequently document what finding? a) Erythema b) Gangrene c) Granulation tissue d) Eschar

d) Eschar

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? a) Small amount of drainage that appears to be mostly fresh blood b) Foul-smelling drainage that is grayish in color c) Copious drainage that is blood-tinged d) Large amounts of drainage that is clear and watery and has no smell

b) Foul-smelling drainage that is grayish in color

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? a) Inform the client that this is an expected occurrence and not to worry b) Allow the wound and intestinal contents to remain open to air c) Apply saline solution-moistened gauze over the protruding area d) Pack the wound with gauze pads and a dry sterile dressing

c) Apply saline solution-moistened gauze over the protruding area

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) A client sitting in a chair who slides down b) A client who lifts himself up on the elbows c) A client who must remain on the back for long periods of time d) A client who lies on wrinkled sheets

a) A client sitting in a chair who slides down

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? a) Stroke the culture swab on surrounding skin first b) Utilize the culture swab to obtain cultures from multiple sites c) Keep the swab and the inside of the culture tube sterile prior to collecting the culture d) Cleanse the wound after obtaining the wound culture

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

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? a) To ambulate using a cane or walker b) To remain in bed for the next 4 hours c) To splint the area when engaging in activity d) To turn the head away from the area whenever coughing

c) To splint the area when engaging in activity

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? a) "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." b) "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." c) "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." d) "This procedure can be safely preformed using clean technique if care is taken not to touch the wound."

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

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? a) Rotate the swab several times over the wound surface to obtain an adequate specimen b) Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen c) Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain d) Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station

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

On inspection, the nurse observes that a neonate has sebaceous retention cysts. The nurse will document the presence of which of the following? a) Prickly heat b) Milia c) Lanugo d) Acne vulgaris

b) Milia

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? a) Removing purulent drainage from the wound bed in order to accurately assess it b) Removing dead or infected tissue to promote wound healing c) Removing excess drainage and wet tissue to prevent maceration of surrounding skin d) Stimulating the wound bed to promote the growth of granulation tissue

b) Removing dead or infected tissue to promote wound healing

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? a) Staging the wound for assessment b) The status of the client's tetanus immunization c) If there is contamination of dirt and debris d) The event leading up to the trauma

b) The status of the client's tetanus immunization

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? a) Clean the wound in a circular pattern, beginning on the perimeter of the wound b) Once the wound is cleaned, gently dry the wound bed with an absorbent cloth c) Clean the wound from the top to the bottom and from the center to outside d) Use clean technique to clean the wound

c) Clean the wound from the top to the bottom and from the center to outside

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? a) Use less packing material b) Assure that the packing material is completely saturated when placed in the wound c) Reduce the time interval between dressing changes d) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead

c) Reduce the time interval between dressing changes

A postoperative client is recovering from a bowel resection. While the nurse is assisting the client with a transfer, the client states "I feel like something just popped." After returning the client safely to bed, which is the nurse's best action? a) Reassure the client that this is expected in the immediate post-op period b) Assess the client for signs of an abdominal hernia c) Document the presence of evisceration d) Promptly assess for dehiscence

d) Promptly assess for dehiscence