FUND PREP U- CH32
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 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.
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?
Braden scale
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
The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication?
Evisceration
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
The nurse is preparing to change a large abdominal dressing in which blood and drainage is expected. In addition to gauze, which dressing supply will the nurse gather to take in the client's room?
Montgomery straps
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
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 nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?
Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown
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 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 recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention?
apply sterile dressings with normal saline over the protruding organs and tissue
A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for:
dehiscence
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
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 nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains?
A Penrose drain promotes drainage passively into a dressing.
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 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 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 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.
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?
"Dehiscence is when a wound has partial or total separation of the wound layers."
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 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 is teaching 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 nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?
"Steri-Strips will hold my wound together until it heals."
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
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
A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?
Biosurgical debridement
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 best action 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 inside of the culture tube sterile.
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 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
Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure injury?
Support the client from sliding in bed.
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
A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform?
Wound irrigation
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
Which is not considered a skin appendage?
connective tissue
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 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
The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot, and injured the worker's foot. What type of injury does the nurse anticipate?
puncture
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 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 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 client's skin through a stab wound created by the surgeon.
true
Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues.
true
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.
• "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."
