Prep u Wound Care

Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a client's wound? Select all that apply.

Position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. • Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. • Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces.

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care the nurse notes the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize with this client's wound?

Proliferation Phase

A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain?

Provides drainage for bile

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Recognize that this is ischemia, followed by reactive hyperemia.

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces?

a client sitting in a chair who slides down

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

A client has developed blisters around the tape that secures the dressing. The nurse should:

apply the dressing with a binder.

A nurse is caring for a client who has recently undergone hernial surgery. What are possible causes of complications with regard to surgical wounds? Select all that apply.

insufficient protein and vitamin C intake • distension of the abdomen from accumulated intestinal gas • weak tissue and muscular support due to obesity

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.

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer?

65-year-old incontinent client with a hip fracture on bed rest

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The oncoming nurse receives in report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

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.

The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

Assess the wound for active bleeding.

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure?

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

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care?

Cleanse with a new gauze for each stroke.

Which is not considered a skin appendage?

Connective tissue

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

Corticosteroids

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

Dehiscence is when a wound has partial or total separation of the wound layers.

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 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 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

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

Do you experience incontinence?"

A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which intervention should the nurse include in the plan to prevent the development of pressure ulcers? Select all that apply.

Encourage client to take fluids every 2 hours. • Turn client every 2 hours while client in bed. • Provide incontinent care every 2 hours and as needed.

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

A nurse assessing the skin of clients knows that the following are health states that may predispose clients to skin alterations. Select all that apply.

Excessive perspiration • Low BMI • Obesity

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing?

Fish

The nurse is caring for a client in the emergency department who cut herself 15 minutes ago while preparing dinner at her home. The nurse understands the client's wound is in which phase of wound healing?

Hemostasis phase

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 of the following actions should the nurse perform in obtaining a wound culture?

Keep the swab and inside of the culture tube sterile.

Which is not a protective function of the skin?

Keratin protects against the sun's ultraviolet rays.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

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

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 describes this?

Secondary intention

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

A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document?

Serosanguineous

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

Stage II

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

Stage III

A nurse assessing client wounds would document which examples of wounds as healing normally without complications? Select all that apply.

The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. • a wound that does not feel hot upon palpation • a wound that forms exudate due to the inflammatory response

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.

Which education points would the nurse use to explain the development of pressure ulcers to clients and how to prevent them?

The skin can tolerate considerable pressure without cell death, but for short periods only." • "Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." • "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation."

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

While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record?

Unintentional, partial-thickness wound

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 ulcer?

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

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 of the following nursing actions should the nurse perform?

Wound irrigation

The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate?

Wounds heal better when a moist wound bed is maintained."

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

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

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

The nurse observes the client for signs of stage I pressure ulcer development, which is most likely to include which finding?

nonblanchable redness

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

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force

A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn?

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