prep u chapter 32

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change.

4Use sterile gloves. 2Cut the foam to the shape and measurement of the wound. 1Place the drape to cover the wound and an additional 3 to 5 cm. 5Cut a 2-cm hole in the drape. 3Apply a vacuum device to wound. 6Ensure that negative pressure has been achieved.

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

"Do you experience incontinence?"

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? "After delivery, I will have sutures in place." "I may have staples in place for a number of days." "I will not remove the staples myself." "Reinforced adhesive skin closures will hold my wound together until it heals."

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

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 client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues? using paper tape on the blisters applying the dressing with a binder applying tape to the side of the blisters applying skin barrier to protect the skin

applying the dressing with a binder

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

preventing the client from sliding in bed

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 hydrocolloid bandage gauze

transparent

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? place a foot board on the bed use pillows to maintain a side-lying position as needed provide incontinent care every 4 hours as needed elevate the head of the bed 90 degrees

use pillows to maintain a side-lying position as needed

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

Diffuse dermatitis accompanied by pruritus

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. The heart must be able to pump adequately. Arteries and veins must be patent and functioning well. The volume of circulating blood must be sufficient.

Local capillary pressure must be lower than external pressure.

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

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

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? The nurse covers the heating pad with a heavy blanket. The nurse places the heating pad under the client's neck. The nurse uses a safety pin to attach the pad to the bedding. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

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

True

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 a small plastic ruler a sterile tongue blade lubricated with water soluble gel an otic curette

a sterile, flexible applicator moistened with saline

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

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." "The surgeon will leave your wound open intentionally for a period of time." "This is a complex reparative process."

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

"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. An individual's skin changes little over the life span. A child's skin becomes less resistant to injury and infection as the child grows. In children younger than 2 years, the skin is thicker and stronger than in adults.

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

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. Document the pain and vital signs. Notify the health care provider of the pain. Administer the prescribed analgesic.

Assess the client's wound and vital signs.

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? Maceration Evisceration Desiccation Necrosis

Desiccation

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it. Administer analgesia before changing the dressing around the drain, if needed. Leave the drain open for 5 to 7 minutes to ensure full drainage. Perform hand hygiene and put on goggles before emptying the drain. Use a gauze pad to clean the drain outlet after emptying it.

Fasten the drain to the client's gown using a safety pin after emptying and recompressing it. Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it.

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 Banana Fish Green beans

Fish

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 III Stage I Stage IV Stage II

Stage II

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

The status of the client's tetanus immunization

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 transparent film a gauze dressing premedicated with antibiotics a dressing with a nonadherent coating

a transparent film

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 bulb-like system will stay in place permanently after your mastectomy." "This drain minimizes the chance for bacteria to enter the surgical site." "You will receive medication through this device."

"It provides a way to remove drainage and blood from the surgical wound."

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

Dehiscence of the wound

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 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

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

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? "This is normal tissue." "Necrotic tissue is devitalized tissue that must be removed to promote healing." "That is called slough, and it will usually fall off." "You are seeing undermining, a type of tissue erosion."

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

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

Discontinue the therapy and assess the client.