Skin Integrity and Wound Care - 1

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate?

"You will likely experience periods of increased skin outbreaks and periods of remissions."

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.

-"Eat nourishing foods after surgery to promote healing." -"Monitor your moods after surgery. Depression after surgery is not normal." - "It may take you longer to heal than someone younger." -"Wound healing can take longer if you have been exposed often to the sun."

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.)

-A wound that requires wound cleaning and irrigation. -A wound that is characterized by oozing from the tissue covering the wound. -A wound with drainage that is a beige color.

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth.

A nurse is obtaining a wound culture from a sacral pressure ulcer. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse?

Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab.

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 client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Penrose drain

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 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 on 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

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?

Soak in a warm bath for drainage.

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 student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 cm × 5 cm with yellow tissue covering the entire wound.

A nurse is caring for a client with a nonhealing stage IV pressure ulcer. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?

Undermining

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

A client has developed blisters around the tape that secures the dressing. What nursing action would be appropriate to prevent further damage to the tissues?

apply the dressing with a binder.

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?

incision

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 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