Fundamentals Chap 26- Skin integrity and wound healing

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?

"I will restrict my diet to fats and carbohydrates."

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 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."

The wound care nurse is performing skin assessments for clients at risk for the development of skin alterations. Which clients does the nurse identify as at greatest risk for skin alterations? Select all that apply. 1. A client with morbid obesity 2. A client with reports of excessive perspiration 3. A client with cataracts 4. A client with hypertension 5. A client that has a low BMI

1, 2, 5

A nurse is caring for clients on a medical-surgical unit. On the basis of known risk factors, the nurse understands that which client has the highest risk for developing a pressure injury?

65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest

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 pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

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

Which statement accurately describes a developmental consideration when assessing skin integrity of clients?

An infant's skin and mucous membranes are injured easily and are subject to infection.

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? A. Stage II B. Stage III

B

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 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

Dehiscence is the softening of tissue due to excessive moisture. True or False

False

A home care nurse is visiting an older adult client. During the visit, the client's spouse sustains a minor thermal injury when cooking. The nurse intervenes, doing which of the following first?

Flush the area with copious amounts of cool water.

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

Gauze

As a part of the senior citizen health program, the community health nurse arranges a free skin screening for the older adults. Which of the following would the nurse find when assessing the skin of older adult clients?

Liver spots

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

A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe the client's wound?

a clean separation of skin and tissue with smooth, even edges

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding?

avulsion

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 assessing a client with a stage 4 pressure injury. What assessment of the injury would be expected?

full-thickness skin loss

A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing of a highly absorbent nature. Which type of dressing should the nurse use for this client?

gauze

What nursing concern is the priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?

infection risk

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

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

The health care provider uses sutures during the surgery on a client at a health care facility. What are sutures?

knotted ties that hold an incision together

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:

laceration

When treating a client for a sprained ankle, the nurse wraps the client's ankle in a bandage. What is the purpose of wrapping the client's ankle in a bandage?

limits movement in the wound area

A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn?

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

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

notify the health care provider and prepare for surgery

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

proliferation phase

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound?

stage 2 pressure injury

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections?

thorough hand hygiene

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