Fundamentals Ch. 32 Skin integrity and Wound care

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? Evisceration of the viscera Infection of the wound Dehiscence of the wound Herniation of the wound

Dehiscence of the wound

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? The nurse uses a ring cushion to protect reddened areas from additional pressure. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. The nurse increases the amount of time the head of the bed is elevated. The nurse places a foam wedge under the body to keep body weight off the client's back.

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

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 margins of your wound are not in direct contact." "This is a complex reparative process." "The surgeon will leave your wound open intentionally for a period of time."

Very little scar tissue will form."

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

a surgical incision with sutured approximated edges

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 gauze dressing precut halfway to fit around the IV line a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics a transparent film

a transparent film

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? dehiscence hemorrhage fistula evisceration

evisceration

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: third degree or full thickness first degree or superficial fourth degree or fat layer second degree or partial thickness

second degree or partial thickness

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?" "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?"

"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 should keep this on my ankle until it is numb." "I will put a layer of cloth between my skin and the ice pack." "I must wait 15 minutes between applications of cold therapy." "I can let this stay on my ankle an hour at a time."

"I will put a layer of cloth between my skin and the ice pack."

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 As a stage II pressure injury As a stage IV pressure injury As a stage III pressure injury

As a stage I pressure injury

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? Superficial abscess accompanied by pruritus Superficial contusion accompanied by pruritus Diffuse fungal infection accompanied by pruritus Diffuse dermatitis accompanied by pruritus

Diffuse dermatitis accompanied by pruritus

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse? Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. Explain to the client that this is not possible because of the health care provider's prescription. Leave the therapy on for 10 more minutes and return to remove it after that time. Assist the client to get out of bed and sit up in a chair for a short while.

Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

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? Arteries and veins must be patent and functioning well. Local capillary pressure must be lower than external pressure. The heart must be able to pump adequately. The volume of circulating blood must be sufficient.

Local capillary pressure must be lower than external pressure.

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 IV Stage III Stage I Stage II

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 Apply an occlusive pressure dressing after removing the staples. Apply adhesive wound closure strips after each staple is removed. Stop removing staples and apply an abdominal pad over the incision.

Stop removing staples and inform the surgeon

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

The status of the client's tetanus immunization

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. False True

True

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 who must remain on his back for long periods of time a client sitting in a chair who slides down a client who lifts himself up on his elbows a client who lies on wrinkled sheets

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 small plastic ruler an otic curette a sterile tongue blade lubricated with water soluble gel a sterile, flexible applicator moistened with saline

a sterile, flexible applicator moistened with saline

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

an obese woman with a history of type 1 diabetes

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? avulsion laceration incision abrasion

incision

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? lubricating the area with skin oil preventing the client from sliding in bed improving the client's hydration pulling the client up from under the arms

preventing the client from sliding in bed

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 maturation tertiary intention primary intention

secondary intention

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? serous serosanguineous purulent sanguineous

serosanguineous

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? "Reinforced adhesive skin closures will hold my wound together until it heals." "I may have staples in place for a number of days." "I will not remove the staples myself." "After delivery, I will have sutures in place."

"Reinforced adhesive skin closures will hold my wound together until it heals."

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 Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. A Penrose drain is a closed drainage system that is connected to an electronic suction device.

A Penrose drain promotes passive drainage into a dressing.

Which is not considered a skin appendage? Eccrine sweat glands Sebaceous gland Hair Connective tissue

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

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

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. Decreased radial pulse No finger numbness or tingling Fingers with quick capillary refill Warm hand Cyanosis

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

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? "Be sure to take at least two showers daily to remove all microorganisms from the skin." "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection."

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

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

"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 drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage."

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

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

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

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? Pasta salad Fish Green beans Banana

Fish

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen? Impaired Skin Integrity related to open wound Knowledge Deficit regarding wound care related to laceration Risk for Infection related to wound Pain related to wound sustained by knife

Impaired Skin Integrity related to open wound

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice? Sterility must be maintained throughout the procedure. It is appropriate to use clean technique during this procedure. The nurse must diligently apply the principles of asepsis. The nurse should apply chlorhexidine or an alternative disinfectant to the wound bed.

It is appropriate to use clean technique during this procedure.

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? Utilize the culture swab to obtain cultures from multiple sites. Cleanse the wound after obtaining the wound culture. Keep the swab and the inside of the culture tube sterile. Stroke the culture swab on surrounding skin first.

Keep the swab and the inside of the culture tube sterile.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. Touch the swab to the intact skin at the wound edges. Tap the outside of the culture tube with the swab before placing it in the tube. Place the swab in the culture tube when done. Press and rotate the swab several times over the wound surfaces. Use the same swab for both wound sites. Insert a swab into the wound.

Place the swab in the culture tube when done. Press and rotate the swab several times over the wound surfaces. Insert a swab into the wound.

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. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain.

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

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound? There is an infection present. The client has wound dehiscence. There is evidence of evisceration. The client has fistula formation.

The client has fistula formation.

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

To splint the area when engaging in activity

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? A superficial partial-thickness burn, which can appear dry and leathery May vary from brown or black to cherry red or pearly white; bullae may be present Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Superficial, which may be pinkish or red with no blistering

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? potassium supplements corticosteroids laxatives antihypertensive drugs

corticosteroids

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? exerting equal, but not excessive, tension with each turn of the bandage keeping the bandage free of gaps between turn elevating and supporting the stump wrapping distally to proximally

elevating and supporting the stump

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document? serosanguineous sanguineous serous purulent

serosanguineous

A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? primary intention tertiary intention quadratic intention secondary intention

tertiary intention

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother: to never trim the baby's nails due to susceptibility to infection. to apply sunscreen when exposed to ultraviolet rays. to only use cloth diapers, since disposable ones can cause eczema. that lanugo is hair of a different color that is permanent.

to apply sunscreen when exposed to ultraviolet rays.

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 decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity. to provide a sinus tract for drainage. to provide drainage for bile.

to provide drainage for bile.