skin integrity and wound care

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

"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 necrotic tissue, which must be removed to promote healing."

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.

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.

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?

Desiccation

A child is brought to the clinic by a parent who states that the child has been at camp. The child has a rash on the face, arms, and legs and says that it itches severely. How will the nurse document the assessment findings?

Diffuse dermatitis accompanied by pruritus

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?

Discontinue the therapy and assess the client.

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?

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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?

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

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?

Reduce the time interval between dressing changes.

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.

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 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?

The status of the client's tetanus immunization

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

To splint the area when engaging in activity

The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound?

an alginate dressing

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

contusion

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?

elevating and supporting the stump

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

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?

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 pale pink drainage on the dressing. Which drainage type should the nurse document?

serosanguineous

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

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?

use pillows to maintain a side-lying position as needed