Skin Integrity & Wound Care

Pressure ulcers form primarily as a result of: a) Tissue ischemia b) Nitrogen buildup in the underlying tissues c) Poor nutrition d) Prolonged illness or disease

a) Tissue ischemia

To reduce pressure points that may lead to pressure ulcers, the nurse should: a) Position the client directly on the trochanter when side-lying b) Massage over the bony prominences c) Elevate the head of the bed as little as possible d) Use a donut device for the client when sitting up

c) Elevate the head of the bed as little as possible

Hydrocolloid dressings

complex formulations of colloid, elastomeric, and adhesive componenets; - adhesive and occlusive - wound contact layer forms a gel as fluid is absorbed and maintains a moist healing environment - absorbs drainage through the use of exudate absorbers in the dressing - maintains wound moisture - slowly liquifies necrotic debris - impermeable to bacteria and other contaminants - is self- adhesive and molds well - acts as preventative dressing for high-risk friction areas - can be left 3-5 days

Wound infection (complications of wound healing)

edges of wound appear inflamed; if drainage present, it is odorous and purulent and causes a yellow, green or brown color

Tissue death occurs when

pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time, leading to tissue ischemia

Braden Scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear

Which of the following assessment findings is most representative of a stage II pressure ulcer? A. A blister B. Undermining C. Nonblanchable redness D. Visible subcutaneous fat

A. A blister

The nurse is assessing a client admitted with complaints related to chronic kidney dysfunction. The nurse recognizes that this client is most likely to present with which of the resulting symptoms? A. Anemia B. Hypotension C. Diabetes mellitus D. Clinical depression

A. Anemia

A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention? A. Cut in the skin from a kitchen knife B. Excoriated perineal area C. Abrasion of the skin D. Pressure ulcer

A. Cut in the skin from a kitchen knife

Following a head injury, the client has thin drainage coming from the left ear. The nurse describes this drainage as: A. Serous B. Purulent C. Cerebrospinal fluid D. Serosanguineous

A. Serous

Application of a warm compress is indicated: A. To improve blood flow to an injured part. B. To protect bony prominences from pressure ulcers. C. To relieve edema. D. For a client who is shivering.

A. To improve blood flow to an injured part.

The client is brought into the emergency department with a knife wound. The nurse correctly documents the client's wound as a(n): 1. Contusion wound 2. Clean wound 3. Acute wound 4. Intentional wound

ANS: 3 A client with a knife wound is an example of an acute wound. An acute wound is caused by trauma from a sharp object. A contusion is a closed wound caused by a blow to the body by a blunt object, resulting in a bruise. A clean wound is a wound that contains no pathogenic organisms, such as a closed surgical wound that does not enter the gastrointestinal, respiratory, or genitourinary system. An intentional wound is a wound resulting from therapy, such as a surgical incision.

The nurse is aware that application of cold is indicated for the client with: 1. Menstrual cramping 2. An infected wound 3. A fractured ankle 4. Degenerative joint disease

ANS: 3 Direct trauma such as fractures or sprains may be treated with cold. The application of cold can initially diminish swelling and pain. Application of heat to reduce muscle tension and reduce pain would be more appropriate for the client with menstrual cramping. The application of cold is not indicated for the client with an infected wound because it reduces the blood flow to the area. This would limit the number of macrophages to clear the area of bacteria and would lessen the nutrient supply to the already impaired tissue. The effects of heat application would be more beneficial to the client with degenerative joint disease.

The nurse is assessing a 78-year-old female African-American client with dark skin. When assessing the skin, the nurse knows to avoid which source of light because it can cast a bluish hue on the skin, making the assessment difficult? 1. Natural sunlight 2. Halogen light 3. Florescent light 4. Incandescent light

ANS: 3 The nurse should avoid a fluorescent light source when assessing dark skin because it casts a bluish hue, making accurate assessment difficult.

When cleaning a wound, the nurse should: 1. Wash over the wound twice and discard that swab 2. Move from the outer region of the wound toward the center 3. Start at the drainage site and move outward with circular motions 4. Use an antiseptic solution followed by a normal saline rinse

ANS: 3 To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in circular rotations outward from a point closest to the drain. The nurse never uses the same piece of gauze or swab to cleanse across an incision or wound twice. The wound should be cleansed in a direction from the least contaminated area, such as from the wound to the surrounding skin. The wound is cleaned from the center region to the outer region. An antiseptic solution is not used to clean a wound, as it may be cytotoxic.

A client with a large abdominal wound requires a dressing change every 4 hours. The client will be discharged to the home setting, where the dressing care will be continued. Which of the following is true concerning this client's wound healing process? 1. An antiseptic agent is best followed with a rinse of sterile saline solution. 2. A heat lamp should be used every 2 hours to rid the wound area of contaminants. 3. Sterile technique should be emphasized to the client and family. 4. A dressing covering will allow the wound area to remain moist.

ANS: 4 A dressing should support a moist wound environment if the wound is healing by secondary intention, such as with a large abdominal wound. A moist wound base facilitates the movement of epithelialization, thus allowing the wound to resurface as quickly as possible. Only mild soap may be used or saline. Antiseptics may be damaging to granulation tissue. A heat lamp should not be used because it will dry out the wound and impair the movement of epithelialization. Clean dressings may be used in the home setting.

The client requires support, and an abdominal binder is ordered. The nurse correctly implements the use of a binder by: 1. Using it as a replacement for underlying dressings 2. Keeping it loose for client comfort 3. Having the client sit or stand when it is applied 4. Making sure the client has adequate ventilatory capacity

ANS: 4 After applying the binder, the nurse should assess the client's ability to ventilate properly, including deep breathing and coughing. Wounds should be entirely covered with dressings; the binder is applied over the dressing. The binder should not be loose, or it will be ineffective in providing support. The client should be lying supine with head slightly elevated and knees slightly flexed for application of the abdominal binder.

The nurse is planning a program on wound healing and includes information that smoking influences healing by: 1. Suppressing protein synthesis 2. Creating increased tissue fragility 3. Depressing bone marrow function 4. Reducing functional hemoglobin in the blood

ANS: 4 Smoking reduces the amount of functional hemoglobin in the blood, thus decreasing tissue oxygenation. Antiinflammatory drugs suppress protein synthesis. Radiation creates tissue fragility. Chemotherapeutic drugs can depress bone marrow function.

Upon inspection of the client's wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select based on the wound assessment is: 1. Foam 2. Hydrogel 3. Hydrocolloid 4. Transparent film

ANS: 1 A foam dressing absorbs exudate and debris while maintaining a moist environment. Topical agents, such as antibiotic ointment, may also be used with a foam dressing. This would be the most appropriate type of dressing for this wound. A hydrogel dressing provides moisture to a clean granular wound. A hydrocolloid dressing interacts with the wound fluid to provide a moist environment. Transparent film protects from friction injury and may be left in place up to 7 days.

Methods for classifying wounds

- describe the status of skin integrity, the cause of the wound, the severity or extent of injury/damage - describe qualities of the wound tissue such as color wound exudate should describe the amount, color, consistency and odor of wound drainage

Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed

1, 3, & 4; Risk factors for pressure ulcers include a low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chance of skin breakdown.

which of the following are measures to reduce tissue damage from shear? (select all that apply) 1. use of transfer device ( transfer board) 2. have head of bed elevated when transferring patient 3. have head of bed flat when repositioning patient 4. raise head of bed 60 degrees when patient positioned supine 5. raise head of bed 30 degrees when patient positioned supine

1, 3, 5

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the suture are open, and pieces of the bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions (select all that apply). 1. notify the surgeon 2. allow the area to be exposed to air until all drainage has stopped 3. place several cold packs over the area, protecting the skin around the wound 4. cover the area with sterile, saline-soaked towels immediately 5. cover the area with sterile gauze and apply an abdominal binder

1, 4

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (select all that apply) 1. frequent position changes 2. keeping the buttocks exposed to air at all times 3. using a large absorbent diaper, changing when saturated 4. using an incontinence cleaner 4. frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. applying a moisture barrier ointment

1,4,6

Risk factors for pressure ulcer development

-impaired sensory perception - alterations in LOC - impaired mobility - shear - friction - moisture

Wound assessment

-observe if edges are closed -observe swelling or separation -note amount, color, odor and consistency of drainage - detect localized areas of tenderness of drainage collection if purulent or suspicious looking drainage, obtain specimen for culture

Implementation - health promotion

-topical skin care and incontinence management - positioning (ever 2 hours) - support surfaces (pillows)

When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional vomiting and is not keeping fluids down well, which of the following would you be most concerned about? 1. Post surgical hemorrhage and anemia 2. Wound dehiscence and evisceration 3. Impaired skin integrity and decubitus ulcers 4. Loss of motility and paralytic illeus

2. Wound dehiscence and evisceration; Wound dehiscence is most likely to occur 4 to 5 days postoperatively, and risk factors include obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration.

Your client has a pressure ulcer over the sacral area that is believed to be due to shearing force. The client's family asks you to explain shearing force. You would be most accurate if you tell the family that shearing force involves: 1. A tearing of the muscle tissue due to a considerable downward force. 2. A sudden break in skin integrity due to being pulled against the bed linens. 3. A superficial skin fold getting pinched, and tissues irritated by the pressure. 4. Superficial skin surface relatively unmoving in relation to the bed surface.

3. A superficial skin fold getting pinched, and tissues irritated by the pressure; Shearing force is a combination of friction and pressure with skin surface unmoving in relation to the bed surface, while deeper tissue attached to the skeleton tends to move with the body.

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1. Alginate 2. Dry Gauze 3. Hydrocolloid 4. No dressing indicated.

3. Hydrocolloid; Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.

Which statement, if made by the client or family member, would indicate the need for further teaching? 1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse. 2. Putting foam pads under the heels or other bony areas can help decrease pressure. 3. If a person cannot turn himself in bed, someone should help them change position q4h. 4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.

3. If a person cannot turn himself in bed, someone should help them change position q4h; Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires additional teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.

You find that your newly assigned client has very shiny skin on their legs, has little or no leg hair, and the client reports that their skin damages easily. You would suspect that these signs and symptoms are related to: 1. Overuse of caustic products to strip the leg hair. 2. Chronic neurological pathology. 3. Impaired peripheral arterial circulation. 4. Inherited reduction in sweat glands and hair follicles.

3. Impaired peripheral arterial circulation; Shiny skin on the legs, reduction in or absence of leg hair, and skin that damages easily is often related to impaired peripheral arterial circulation.

Cleaning the skin

1. Clean in direction from the least contaminated area to the surrounding skin 2. use gentle friction when applying solutions locally to the skin 3. when irrigating, allow the flow from the least to the most contaminated

Proper technique for performing a wound culture includes what? 1. Cleansing the wound prior to obtaining the specimen. 2. Swabbing for the specimen in the area with the largest collection of drainage. 3. Removing crusts or scabs with sterile forceps and then culturing the site beneath. 4. Waiting 8 hours following a dose of antibiotic to obtain the specimen.

1. Cleansing the wound prior to obtaining the specimen; Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride a wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a does will not significantly affect the concentration of wound organisms.

When working with an older person, you would keep in mind that the older person is most likely to experience which of following changes with aging? 1. Thinning of the epidermis 2. Thickening of the epidermis 3. Oiliness of the skin 4. Increased elasticity of the skin

1. Thinning of the epidermis, The epidermis thins with aging, and there is decreased strength and elasticity of the skin, increased dryness and scaliness of the skin, and diminished pain perception due to decreased sensation of pressure and light touch.

When receiving a report at the beginning of your shift, you learn that your assigned client has a surgical incision that is healing by primary intention. You know that your client's incision is: 1. Well approximated, with minimal or no drainage. 2. Going to take a little longer than usual to heal. 3. Going to have more scarring than most incisions. 4. Draining some serosanguineous drainage.

1. Well approximated, with minimal or no drainage; Primary intention means that the wound edges are well approximated, with minimal or no tissue loss as well as formation of minimal granulation tissue and scarring.

Match the pressure ulcer categories/stages with the correct definition. 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 a. nonblachale redness of intact skin. Discoloration, warmth, edema or pain may also be present b. full-thickness skin loss; subcutaneous fat may be visible. may include undermining c. full thickness tissue loss; muscle and bone visible. may include undermining. d. partial thickness skin loss or intact blister with serosanguinous fluid

1. a, 2. d, 3. b 4. c

What is the removal of devitalized tissue from a wound called? 1. debridement 2. pressure reduction 3. negative pressure wound therapy 4. sanitization

1. debridement

Match A. Stage I B. Stage III C. Stage II D. Stage IV E. Unstageable 1. Nonblanchable Redness of Intact Skin 2. Partial-thickness Skin Loss or Blister 3. Full-thickness Skin Loss (Fat Visible) 4. Full-thickness Tissue Loss (Muscle/Bone Visible) 5. Full-thickness Skin or Tissue Loss—Depth Unknown

1: A, 2: C, 3: B, 4: D, 5: E

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (select all that apply) 1. collection of wound drainage 2. providing support to abdominal tissues when coughing or walking 3. reduction of abdominal swelling 4. reduction of stress on the abdominal incision 5. stimulation of peristalsis from direct pressure

2, 4

You are caring for an assigned client and notice a superficial ulcer on the client's buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

2. Stage II; Stage I pressure ulcer involves a nonblanchable erythema of intact skin, while a stage II involves a partial-thickness skin loss involving epidermis, dermis, or both, with the ulcer being superficial and presenting as an abrasion, blister, or shallow crater.

The nurse is caring for a 23-year-old male client who is in the ICU with second and third degree burns over 40 percent of his body. One of the first symptoms that the client is having organ failure is that the urine output is less than: A. 30 mL/hour B. 40 mL/hour C. 50 mL/hour D. 60 mL/hour

A. 30 mL/hour

Which of the following preoperative assessment findings would most likely delay a planned procedure requiring general anesthetic? A. A cough and low-grade fever B. The pulse oximetry reading of 97% on room air C. A blood pressure that is 5 systolic points higher than baseline D. The client's report of "being so nervous about this procedure"

A. A cough and low-grade fever

You are at the scene of an accident and find the victim has a bleeding lower leg wound. After flushing the wound with water and covering it with a clean dressing, you find the dressing has been saturated with blood. Which of the following would be the best action to take in this case? 1. Lower the extremity while applying pressure to the wound. 2. Take off the first dressing and apply another clean or sterile dressing. 3. Encircle the client's ankle with your hands and apply pressure. 4. Reinforce the first layer of dressing with a second layer of dressing.

4. Reinforce the first layer of dressing with a second layer of dressing; To control severe bleeding, apply direct pressure to the wound and elevate the extremity. If the dressing becomes saturated, apply a second layer. Removing the first dressing may disturb blood clots and increase the bleeding.

Which of the following describes a hydrocolloid dressing? 1. a seaweed derivative that is highly absorptive 2. premoistened gauze placed over a granulating wound 3. a debriding enzyme that is used to remove necrotic tissue 4. a dressing that forms a gel that interacts with the wound surface

4. a dressing that forms a gel that interacts with the wound surface

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. local skin infection requiring abx 2. sensitive skin that requires special bed linen 3. a stage 3 pressure ulcer needing the appropriate dressing 4. blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. necrotic tissue 2. wound drainage 3. wound circumference 4. cleansed wound

4. cleansed wound

Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter? A. Empty the drainage bag at least every 8 hours. B. Clean up the length of the catheter to the perineum. C. Use clean technique to obtain a specimen for culture and sensitivity. D. Place the drainage bag on the client's lap while transporting the client to testing.

A. Empty the drainage bag at least every 8 hours.

Which of the following interventions does the nurse use the maintain the skin moisture of a patient at risk for pressure injury? A. Keep the skin dry and well lubricated B. Reposition the patient every two hours C. Relieve pressure on heels D. Place pressure on relieving surface of the patient's bed

A. Keep the skin dry and well lubricated

A client with a history of sleep apnea has had a same-day surgery procedure that will require the administration of morphine postoperatively to manage pain. This client will be assessed most appropriately by the perioperative nurse for the risk for respiratory complications by frequently: A. Listening to breath sounds B. Monitoring pulse oximetry C. Evaluating spirometer use D. Counting respirations per minute

A. Listening to breath sounds

When changing the soiled linen on the bed of a client who is comatose, the nurse notices a reddened, blanchable area approximately 2 cm in diameter on her left buttock. The nurse's initial skin breakdown intervention is to: A. Position the client on her right side B. Finish providing fresh, dry linen to the client's bed C. Include a 2-hour turning schedule in the client's care plan D. Measure the area in order to describe it in the nurses' notes

A. Position the client on her right side

A 74-year-old is accompanied by his daughter to the ambulatory surgery department for the surgical removal of a suspicious skin lesion. The client has experienced dysphasia since a cerebral vascular accident 3 years ago. The most effective way for the nurse to secure the necessary preoperative interview information is to: A. Question the client's daughter B. Review the client's past medical records C. Present the questions in a simple format D. Counting respirations per minute

A. Question the client's daughter

During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include: A. Repositioning the client off the coccygeal area and reassessing the area in 1 hour B. Inserting a urinary catheter to prevent accumulation of moisture from urinary incontinence C. Placing the client in Fowler's position and returning in 2 hours D. Massaging the reddened area and repositioning the client

A. Repositioning the client off the coccygeal area and reassessing the area in 1 hour

Which type of pressure ulcer consists of an observable pressure-related alteration of intact skin that may show changes in skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching) compared with an adjacent or opposite area on the body? A. Stage I B. Stage II C. Stage III D. Stage IV

A. Stage I

When a wound specimen is obtained for culture to determine whether infection is present, the specimen should to be taken from: A. The wound after it has first been cleansed with normal saline B. Drainage on the dressing C. Wound drainage D. Necrotic tissue

A. The wound after it has first been cleansed with normal saline

When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should: A. Use a needle to withdraw urine from the catheter port B. Open the drainage bag and removing urine C. Withdraw urine from a urinometer D. Disconnect the catheter from the drainage tubing

A. Use a needle to withdraw urine from the catheter port

The client will have an incision in the left lower abdomen. Which of the following measures by the nurse will help decrease discomfort in the incisional area when the client coughs postoperatively? A. applying a splint directly over the lower abdomen B. keeping the client flat with her feet relaxed C. turning the client onto the right side D. applying pressure above and below the incision

A. applying a splint directly over the lower abdomen

A client who is scheduled for surgery is found to have thrombocytopenia. A specific postoperative concern for the nurse for this client is: A. Hemorrhage B. Wound infection C. Fluid imbalance D. Respiratory depression

A. hemorrhage

The nurse is completing the pre-op checklist for an adult client who is schedule for an operative procedure later in the morning. Which of the following pre-op assessment findings for this client indicates a need to contact the anesthesiologist? A. temp 100 F B. pulse 90 bpm C. resp 20 breaths per minute D. BP 130/74 mm Hg

A. temp 100 F

A cognitively impaired client spends hours a day involuntarily wringing her hands. Which of the following interventions is the most therapeutic as a means of minimizing this client's risk for friction damage to her hands? 1. Placing thin cotton mitts on her hands 2. Frequently distracting her with conversation 3. Regularly reminding her to stop wringing her hands 4. Getting a prescription to minimize the compulsive behavior

ANS: 1 A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The remaining options are not as likely to be effective with a cognitively impaired client.

The nurse uses the Norton scale in the extended care facility to determine the client's risk for pressure ulcer development. Which one of the following scores, based on this scale, places the client at the highest level of risk? 1. 6 2. 8 3. 15 4. 19

ANS: 1 According to the Norton scale, a lower score indicates a higher risk for pressure ulcer development. The total score ranges from 5 to 20. The client at highest risk would be the client with a score of 6.

The client is experiencing low back pain and is to have an aquathermia pad applied. The nurse recognizes that safe application of heat to a client's injury includes: 1. Providing a timer for the client 2. Allowing the client to adjust the temperature for comfort 3. Placing the pad directly onto the area requiring treatment 4. Using the highest temperature that is tolerated by the client

ANS: 1 An application should last only 20 to 30 minutes. Providing a timer for the client will help prevent injury to the tissue. The temperature setting is fixed by inserting a plastic key into the temperature regulator. In many institutions the central supply room sets the regulators to the recommended temperature. The nurse does not place the pad directly on the client's skin. To prevent injury, it should be covered with a thin towel or pillow case. The recommended temperature is 105° to 110° F. The pad should not be used at the highest temperature that is tolerated by the client.

Wounds that heal by primary intention will most likely: 1. Have minimal scarring 2. Contain infected tissue 3. Present with ragged edges 4. Have portions of missing tissue

ANS: 1 Healing occurs by epithelialization; these wounds heal quickly with minimal scar formation.

The inflammatory stage of healing is characterized by: 1. Throbbing pain 2. Granulation tissue 3. Wound contraction 4. Collagen scarring

ANS: 1 Localized redness, edema, warmth, and throbbing pain are characteristics of the inflammatory stage of healing.

Which of the following interventions is mostly likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose? 1. Turn and position the client at least every 2 hours. 2. Use a lift sheet when moving the client up in the bed. 3. Change wet, soiled clothing as promptly as it is detected. 4. Keep the head of the client's bed elevated to less than 30 degrees.

ANS: 1 Pressure is the major cause in pressure ulcer formation, and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pressure

When changing the soiled linen on the bed of a client who is comatose, the nurse notices a reddened, blanchable area approximately 2 cm in diameter on her left buttock. The nurse's initial skin breakdown intervention is to: 1. Position the client on her right side 2. Finish providing fresh, dry linen to the client's bed 3. Include a 2-hour turning schedule in the client's care plan 4. Measure the area in order to describe it in the nurses' notes

ANS: 1 Pressure is the major cause in pressure ulcer formation, and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pressure. The remaining options are appropriate, but none has priority over proper positioning of the client.

Upon changing the client's dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is: 1. Sterile saline 2. Hydrogen peroxide 3. Povidone-iodine (Betadine) 4. Sodium hypochlorite (Dakin's solution)

ANS: 1 Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic, such as normal saline. Normal saline will not damage or kill cells, such as fibroblasts and healing tissue. Hydrogen peroxide, povidone-iodine (Betadine), and sodium hypochlorite (Dakin's solution) are cytotoxic and therefore should not be used to clean a wound that is granulating.

Following a head injury, the client has thin drainage coming from the left ear. The nurse describes this drainage as: 1. Serous 2. Purulent 3. Cerebrospinal fluid 4. Serosanguineous

ANS: 1 Serous drainage is clear, watery plasma. Purulent drainage is thick, yellow, green, tan, or brown. Drainage must be tested to determine if it is cerebrospinal fluid. The nurse should describe the drainage by its appearance (i.e., serous). Serosanguineous drainage is pale, red, and watery, a mixture of clear and red fluid.

Which of the following assessment findings is most representative of a stage II pressure ulcer? 1. A blister 2. Undermining 3. Nonblanchable redness 4. Visible subcutaneous fat

ANS: 1 Stage II ulcers have partial-thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. The remaining options describe elements of stage I and stage III ulcers.

The initial nursing intervention for the assessment of external hemorrhaging is: 1. Close monitoring of the wound dressing for bloody drainage 2. Frequent assessment of the client's blood pressure 3. Monitoring of the client's heart rate 4. Redressing of the wound

ANS: 1 The nurse observes dressings covering the wound for bloody drainage.

When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? 1. Clean the area with mild soap, dry, and add a protective moisturizer. 2. Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area. 3. Soak the area in normal saline solution. 4. Wash the area with an astringent and paint it with povidone-iodine (Betadine).

ANS: 1 The skin should be cleansed and completely dried and a protective moisturizer applied to keep the epidermis well lubricated. Hydrogen peroxide is cytotoxic and should not be used. A heat lamp is not necessary and would increase the client's risk for an accidental burn. The area should not be soaked because this may lead to maceration of the skin. The area should not be cleansed with an astringent and painted with povidone-iodine. An astringent may cause excessive drying of the tissue, and povidone-iodine is cytotoxic.

The 23-year-old female client is concerned about scarring from her hernia surgery. She had a third-degree burn on her right arm when she was younger that left a scar that she is self-conscious about. Then nurse explains to the client that the wound from the burn healed differently than the surgical incision will heal. The incision that she will have will heal by: 1. Primary intention 2. Secondary intention 3. Tertiary intention 4. Dehiscence

ANS: 1 The surgical wound heals by primary intention. The skin edges are approximated, or closed, and the risk for infection is low. Healing occurs quickly; with minimal scar formation, as long as infection and secondary breakdown is prevented. Healing occurs by epithelialization. A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by secondary intention. The wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention, and thus the chance of infection is greater. In tertiary intention, a wound is left open for several days, then wound edges are approximated. This type of healing is for wounds that are contaminated and require observation for signs of inflammation. Closure of wound is delayed until risk for infection is resolved. When a wound fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury). Dehiscence is the partial or total separation of wound layers.

Which of the following clients have an increased risk for the development of a pressure ulcer? (Select all that apply.) 1. A 35-year-old motorcycle accident victim who has been comatose for 5 months 2. A 75-year-old client with type 2 diabetes with neuropathy in his feet 3. A 64-year-old client experiencing anorexia after hip replacement surgery 4. A 70-year-old client diagnosed with advanced Alzheimer's disease 5. A 40-year-old client with osteoarthritis who has been in bed with the flu 6. A 25-year-old client in the terminal stages of brain cancer

ANS: 1, 2, 3, 4, 6 Any client experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development. The only option that does not represent one of the risk factors is the client dealing with the flu.

Which of the following statements best reflects the nurse's role in the health and maintenance of a client's skin? (Select all that apply.) 1. "I'll note on the client's care plan to apply lotion to her dry elbows." 2. "I'm on my way in to turn the client. Will you be able to help me?" 3. "The ancillary staff tells me that her skin is generally very dry." 4. "The pressure ulcer on her hip has really gotten smaller." 5. "Can you bring in some scented lotion for your mom?" 6. "A 1.5-cm reddened area noted on client's left heel."

ANS: 1, 2, 4, 6 One of the nurse's most important responsibilities is to monitor skin integrity and to plan, implement, and assess interventions to maintain skin integrity. The remaining options do not reflect nursing interventions—one reflects ancillary staff, and the other does not really mention the therapeutic role of the request.

The client has a stage IV pressure ulcer. In accordance with the Agency for Healthcare Research and Quality (AHRQ), the nurse recommends that the client should have a(n): 1. Foam mattress 2. Air-fluidized bed 3. Rotokinetic bed 4. Static support surface

ANS: 2 Air-fluidized beds are recommended for clients with burns or multiple stage III or stage IV pressure ulcers. A foam mattress is recommended for pressure reduction in clients at high risk for developing a pressure ulcer. A Rotokinetic bed is recommended for clients who are at risk for or have developed atelectasis and/or pneumonia. A static support surface is not recommended for a client with a stage IV ulcer. It is used for clients at high risk for developing a pressure ulcer.

Which of the following clients is most at risk for developing a pressure ulcer? 1. 3-year-old in Buck's traction 2. 33-year-old comatose client 3. 76-year-old client who has had a mild stroke 4. 38-week-old infant in an oxygen hood

ANS: 2 Clients in a coma cannot perceive pressure and are unable to move voluntarily to relieve pressure.

A client comes to the emergency department following an injury. The nurse implements appropriate first aid for the client when: 1. Removing any penetrating objects 2. Elevating an affected part that is bleeding 3. Vigorously cleaning areas of abrasion or laceration 4. Keeping any puncture wounds from bleeding

ANS: 2 If a client is bleeding, the nurse applies direct pressure and elevates the affected part. When a penetrating object is present, it is not removed. Removal could cause massive, uncontrolled bleeding. Vigorous cleaning can cause bleeding or further injury. Abrasions and minor lacerations should be rinsed with normal saline and lightly covered with a dressing. Puncture wounds are allowed to bleed to remove dirt and other contaminants.

A client requires wound debridement. The nurse is aware that which one of the following statements is correct regarding this procedure? 1. It allows the healthy tissue to regenerate. 2. When performed by autolytic means, the wound is irrigated. 3. Mechanical methods involve direct surgical removal of the eschar layer of the wound. 4. Enzymatic debridement may be implemented independently by the nurse whenever it is required.

ANS: 2 Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base necessary for healthy tissue to regenerate. Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. The wound is not irrigated. Mechanical methods include wet-to-dry dressings, wound irrigation, and whirlpool treatments. Surgical debridement involves direct surgical removal of the eschar layer of the wound. Enzymatic debridement requires a health care provider's order.

A client presents with a pressure ulcer that the nurse is documenting in the medical record. The nurse notes necrotic tissue on the pressure ulcer, which indicates that: 1. The pressure ulcer is automatically a stage IV 2. The pressure ulcer cannot be staged 3. The client has been abused 4. The pressure ulcer is healing

ANS: 2 Staging systems for pressure ulcers are based on describing the depth of tissue destroyed. Accurate staging requires knowledge of the skin layers, and a major drawback of a staging system is that you cannot stage an ulcer covered with necrotic tissue because the necrotic tissue is covering the depth of the ulcer. The necrotic tissue must be debrided or removed to expose the wound base to allow for assessment. The necrotic tissue present on the pressure ulcer doesn't necessarily indicate that the client has been abused, nor does it indicate that the wound is healing.

The nurse prepares to irrigate the client's wound. The primary reason for this procedure is to: 1. Decrease scar formation 2. Remove debris from the wound 3. Improve circulation from the wound 4. Decrease irritation from wound drainage

ANS: 2 The gentle washing action of the irrigation cleanses a wound of exudate and debris. The primary purpose of wound irrigation is not to improve circulation, decrease scar formation, or decrease irritation from wound drainage, but to remove debris from the wound.

The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is: 1. A reduced skin elasticity is common in the older adult 2. The attachment between the epidermis and dermis is weaker 3. The older client has less subcutaneous padding on the elbows 4. Older adults have a poor diet that increases risk for pressure ulcers

ANS: 3 Although all the options are related to causes of skin injury in older adults, the hypodermis decreases in size with age, and so the older client has little subcutaneous padding over bony prominences; thus they are more prone to skin breakdown.

When asked what the role of the skin is in maintaining homeostasis, the answer that reflects the greatest insight is: 1. "Our body needs vitamin D, and without healthy skin we cannot utilize it into a form we can use." 2. "Without skin we would not be able to enjoy the sense of touch that is so important to us as humans." 3. "The skin is a barrier that is really quite good at keeping disease-causing pathogens from getting into our body." 4. "It is the pain with its pain receptors that alert us to danger so that we can take appropriate action in order to be safe."

ANS: 3 Although it is a sensory organ for pain, temperature, and touch and synthesizes vitamin D, its primary role is that of a protective barrier against disease-causing organisms.

Which of the following statements shows the greatest understanding of wound staging? 1. "An ulcer must involve broken skin in order to be staged." 2. "A wound that contains slough is difficult to stage." 3. "This wound can't be staged until it's debrided." 4. "The health care provider will need to stage the ulcer."

ANS: 3 An unstageable ulcer is a full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore the stage cannot be determined. The remaining options are not correct.

A client has a healing abdominal wound. The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing? 1. Primary intention 2. Inflammatory phase 3. Proliferative phase 4. Secondary intention

ANS: 3 During the proliferative phase, the wound fills with granulation tissue (including collagen formation), the wound contracts, and the wound is resurfaced by epithelialization. Primary intention is not a phase of wound healing. Wounds that heal by primary intention have minimal tissue loss, such as a surgical wound. The edges are approximated and the risk for infection is low. During the inflammatory phase, platelets gather to stop bleeding, a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris. Secondary intention is not a phase of wound healing. Wounds that heal by secondary intention have loss of tissue, such as a pressure ulcer. The wound is left open until it becomes filled by scar tissue.

To reduce pressure points that may lead to pressure ulcers, the nurse should: 1. Position the client directly on the trochanter when side-lying 2. Use a donut device for the client when sitting up 3. Elevate the head of the bed as little as possible 4. Massage over the bony prominences

ANS: 3 Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. The client should not be positioned directly on the trochanter because this can create pressure over the bony prominence. Donut-shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia. Bony prominences should not be massaged. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk for injury to underlying tissue and pressure ulcer formation.

The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the client who has exposure to: 1. Urine 2. Purulent exudates 3. Pancreatic fluids 4. Serosanguineous drainage

ANS: 3 Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Exposure to urine, bile, stool, acetic fluid, and purulent wound exudates carries a moderate risk for skin breakdown. Serosanguineous drainage is not caustic to the skin, and the risk for skin breakdown from exposure to this fluid is low.

The nurse is assessing the pressure ulcer of a 68-year-old female client. Which of the following would indicate to the nurse that healing is taking place? 1. Eschar 2. Slough 3. Granulation tissue 4. Exudate

ANS: 3 Granulation tissue is red moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Black or brown necrotic tissue is eschar which you will need to remove before healing can proceed. Soft, yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and you will need to remove this before the wound is able to heal. Wound exudate describes the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. Excessive exudate indicates the presence of infection. The presence of exudate on the skin surrounding the wound is indicative of wound deterioration.

Granulated tissue is best described as: 1. Soft, yellow, and stringy 2. Black, hard, and necrotic 3. Red, moist, and vascular-rich 4. Yellow, spongy, and sinewy

ANS: 3 Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft, yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and you will need to remove this before the wound is able to heal. Black or brown necrotic tissue is eschar, which you will also need to remove before healing can proceed.

Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client? 1. "2-cm area of scaly, dry skin located on the client's right heel." 2. "2-cm area of nonblanching erythema located on the client's right heel." 3. "2-cm area purplish blue in color surrounded by lighter-colored skin located on right heel." 4. "2-cm area of blanching erythema located on the client's right heel; entire foot warm to the touch."

ANS: 3 In dark-skinned individuals areas of pressure appear darker than surrounding skin and have a purplish/bluish hue; the temperature of the area may be warm or cool to the touch. The remaining options use descriptives not applicable to the dark-skinned individual or less definite indicators.

Which of the following statements made by the nurse shows the greatest insight into the need to manage the risk factors that contribute to the formation of a pressure ulcer? 1. "Her diet needs to include more protein and less sugary foods." 2. "She needs to be moved more gently and with attention to her skin." 3. "We need to decrease the time she spends with the weight of her body resting on her hip 4. "The urinary incontinency makes the risk for developing a pressure ulcer so much greater for her."

ANS: 3 Pressure is the major cause in pressure ulcer formation. Three pressure-related factors contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance. The remaining options, although related to contributing factors, do not address the primary factor, pressure.

Pressure ulcers form primarily as a result of: 1. Nitrogen buildup in the underlying tissues 2. Prolonged illness or disease 3. Tissue ischemia 4. Poor nutrition

ANS: 3 Pressure is the major cause of pressure ulcer formation. Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. Prolonged illness or disease and poor nutrition may place a client at risk for pressure ulcer development.

Although all of the following represent poor transfer techniques, which is most likely to result in a shearing injury to the skin of an older adult client? 1. Only one staff member positioning an immobile client 2. Allowing the heels to be dragged as the client is being positioned 3. Failing to lower the head of the bed before moving the client upward 4. Neglecting to use a lift sheet when moving the client to the head of the bed

ANS: 3 Shear is the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. The remaining options result in friction damage to the client's skin.

The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the client's skin integrity? 1. Having the client sit up in a chair for 4-hour intervals 2. Keeping the head of the bed in a high-Fowler's position to increase circulation 3. Keeping a written schedule of turning and positioning 4. Encouraging the client to perform pelvic muscle training exercises several times a day

ANS: 3 The frequency of repositioning should be individualized for the client; however, clients should be repositioned at least every 2 hours. The Agency for Healthcare Research and Policy (AHRQ) guidelines recommend that a written turning and positioning schedule be used. Clients able to sit in a chair should be limited to sitting for 2 hours or less. Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. Pelvic muscle training may help prevent incontinence, but it is not the best intervention for maintaining the client's skin integrity.

The nursing student is bathing a 73-year-old Native American female client. The student reports to the nurse that the client has what looks like cyanosis on her sacrum. The nurse goes with the student to assess the client but suspects that the cyanosis that the student sees is most likely: 1. Caused from the client laying on her back most of the morning 2. Caused by the bright sunlight in the room 3. Normal hyperpigmentation of mongolian spots 4. Blue dye that has bled off the cheap new gowns that the hospital has purchased

ANS: 3 The nurse should not confuse the normal hyperpigmentation of mongolian spots that are seen on the sacrum of African, Native American, and Asian clients as cyanosis. Observe the client's skin in nonglare daylight. The Gaskin's Nursing Assessment of Skin Color (GNASC) is a useful tool for assessment for identifying changes in skin color that increase the client's risk for pressure ulcers.

The nurse determines that the client's wound may be infected. To perform an aerobic wound culture, the nurse should: 1. Collect the superficial drainage 2. Collect the culture before cleansing the wound 3. Obtain a culturette tube and use sterile technique 4. Use the same technique as for collecting an anaerobic culture

ANS: 3 The nurse uses different methods of specimen collection for aerobic or anaerobic organisms. To collect an aerobic wound culture, the nurse uses a sterile swab from a culturette tube and sterile technique. The nurse never collects a wound culture sample from old or superficial drainage. Resident colonies of bacteria from the skin grow in superficial drainage and may not be the true causative organisms of a wound infection. The nurse should clean a wound first with normal saline to remove skin flora before obtaining the culture.

A client on the medical unit is taking steroids and also has a wound from a minor injury. To promote wound healing for this client, the nurse recommends that which of the following be specifically added? 1. Iron 2. Folic acid 3. Vitamin A 4. B complex vitamins

ANS: 3 Vitamin A can reverse steroid effects on skin and delayed healing. Iron does not reverse the effects of steroids. It is important in the transport of oxygen. Folic acid does not reverse the effects of steroids. It is a B complex vitamin needed for DNA synthesis. The B complex vitamins do not reverse the effects of steroids. The B vitamins affect growth and stimulate appetite, lactation, and the gastrointestinal, neurological, and endocrine systems.

The nurse is concerned that the client's midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication? 1. Administering antibiotics to prevent infection 2. Using appropriate sterile technique when changing the dressing 3. Keeping sterile towels and extra dressing supplies near the client's bed 4. Placing a pillow over the incision site when the client is deep breathing or coughing

ANS: 4 A strategy to prevent dehiscence is to use a folded thin blanket or pillow placed over an abdominal wound when the client is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure. A client who has an infection is at risk for poor wound healing and dehiscence. However, prophylactic use of antibiotics is not the best intervention to prevent dehiscence. Using appropriate sterile technique is always important to prevent the development of infection but is not the best intervention to prevent dehiscence.

In reviewing the client's nutritional intake, the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity. The nurse suggests that the client eat: 1. Fish 2. Eggs 3. Liver 4. Citrus fruits

ANS: 4 Citrus fruits contain vitamin C, which is important in collagen synthesis, capillary wall integrity, and fibroblast function. Fish and eggs contain protein and vitamin E. Protein plays a role in neogenesis, collagen formation, and wound remodeling. Liver contains vitamin A, which is important in epithelialization and wound closure.

Which of the following statements made by the nurse shows the most thorough understanding of the therapeutic value of testing a reddened area on the heel of a mobility-impaired client for blanching? 1. "If it blanches, the problem isn't too bad." 2. "When it stays red, the damage is great." 3. "Nonblanching hyperemia is a poor indictor of healing." 4. "Blanching denotes an attempt to deliver blood to the site."

ANS: 4 If the area blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanching hyperemia. If, however, the erythemic area does not blanch (nonblanching erythema) when you apply pressure, deep tissue damage is probable.

The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by: 1. Filling two thirds of the wound cavity 2. Leaving saline-soaked folded gauze squares in place 3. Putting the dressing in very tightly 4. Extending only to the upper edge of the wound

ANS: 4 The wound should be packed only until the packing material reaches the surface of the wound. Wound packing that overlaps onto the wound edges can cause maceration of the tissue surrounding the wound. It can also impede the proper healing and closing of the wound. The wound should be packed to the upper edge of the wound to prevent dead space and the formation of abscesses. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. The wound should not be packed too tightly. Overpacking the wound may cause pressure on the tissue in the wound bed.

Which nursing entry is most complete in describing a client's wound? 1. Wound appears to be healing well. Dressing dry and intact. 2. Wound well approximated with minimal drainage. 3. Drainage size of quarter; wound pink, 4 × 4s applied. 4. Incisional edges approximated without redness or drainage; two 4 × 4s applied.

ANS: 4 This is the most complete description of the client's wound. It describes the wound according to characteristics observed and the dressing that covers it. Wounds should be measured using the metric system, not described as the size of objects.

The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape: 1. At a 45-degree angle to the skin surface while pulling away from the wound 2. At a right angle to the skin surface while pulling toward the wound 3. At a right angle to the skin surface while pulling away from the wound 4. Parallel to the skin surface while pulling toward the wound

ANS: 4 To remove tape safely, the nurse loosens the tape ends and gently pulls the outer end parallel with the skin surface toward the wound. Tape should not be pulled in a direction away from the wound because this may cause the wound edges to separate. Holding the tape at a right angle to the skin surface may pull on the wound bed, causing separation of wound layers, or may damage the underlying skin.

The nurse notes that the 43-year-old male client has an abrasion on his upper right thigh that he received 2 days ago when he was involved in a bicycle accident. The abrasion is red, swollen, warm, and throbbing. The nurse knows that the wound shows signs of being: 1. Infected 2. In the inflammatory phase of healing 3. In the proliferative phase of healing 4. In the remodeling phase of healing

ANS: 2 The inflammation stage is the body's reaction to wounding and begins within minutes of injury and lasts approximately 3 days. The inflammatory response is beneficial, and there is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a closed compartment. Some contaminated or traumatic wounds show signs of infection early, within 2 to 3 days. The client has a fever, tenderness and pain at the wound site, and an elevated white blood cell count. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism. With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization. Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound.

The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

ANS: 2 This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Wounds that are contaminated or infected heal by: 1. Secondary intention 2. Tertiary intention 3. Primary intention 4. Open intention

ANS: 2 Wounds that are contaminated and require observation for signs of inflammation are left open for several days. When wound edges are approximated; this is tertiary intention healing.

Proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? (Select all the apply.) 1. Presence of pain 2. Depth of damage 3. Length and width 4. Presence of drainage 5. Description of drainage 6. Condition of surrounding tissue

ANS: 2, 3, 4, 5, 6 Assessment includes depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin. Presence of pain is not a component of this charting.

Which of the following clients has the greatest risk for friction-induced skin breakdown? 1. A client who is obese and is frequently incontinent of both urine and feces 2. A client who insists she is comfortable only when positioned on her left side 3. A client who is cognitively impaired and comforts herself by wringing her hands 4. An immobile client who slides down in the recliner where he spends the morning hours

ANS: 3 A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The other options represent friction or moisture factors that contribute to skin breakdown.

A 24-year-old male client has been scheduled to undergo surgery for an ACL repair of his right knee. The client states that he is confused about what the surgeon will be doing. The best response from the nurse is: A. "The surgeon went over this procedure with you in his office" B. "Let me get the surgeon to talk with you before we proceed so that you fully understand what will be happening" C. To share with the client what he can expect in regard to the procedure D. "This is just a simple procedure—you should feel much better afterwards"

B. "Let me get the surgeon to talk with you before we proceed so that you fully understand what will be happening"

There are a number of risk factors for pressure injury. According to the Braden Scale, what are the risk factors? 1. Inability to change position in bed 2. Ability to self-report pain level 3. Frequent linen change during a shift 4. Impaired level of consciousness 5. Adequate nutrition A. 1,2,3,4 B. 1,3,4 C. 2,3,4 D. 1,2,3,4,5

B. 1,3,4

Which of the following clients is most at risk for developing a pressure ulcer? A. 3-year-old in Buck's traction B. 33-year-old comatose client C. 76-year-old client who has had a mild stroke D. 38-week-old infant in an oxygen hood Clients in a coma cannot perceive pressure and are unable to move voluntarily to relieve pressure.

B. 33-year-old comatose client

The nurse is to collect a specimen for culture after assessing the client's wound drainage. The best technique for obtaining the culture is to: A. Collect the specimen from accumulated drainage. B. Cleanse the wound first. C. Swab from the outside skin edge inward. D. Send the soiled dressing to the laboratory.

B. Cleanse the wound first.

Which of the following goals is most appropriate for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information? A. Client will understand the need for scheduled surgery before leaving the provider's office. B. Client will understand the preoperative routines of surgical care before leaving provider's office. C. Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery. D. Client will be able to successfully accomplish the preoperative bowel preparation by morning of scheduled surgery.

B. Client will understand the preoperative routines of surgical care before leaving provider's office.

Given a rationale for preoperative and postoperative procedures, the client is better prepared to participate in care. For which of the following should the nurse provide instruction and rationale? A. Using the patient-controlled analgesia (PCA) pump B. Incentive spirometry C. Working the call button for the nurse D. Specific details regarding the progression of diet

B. Incentive spirometry

The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

B. Stage 2

Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, which results in tissue ischemia and ultimately tissue death. There are four stages of pressure ulcer formation. The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage of ulcer will the nurse document? A. Stage I B. Stage II C. Stage III D. Stage IV

B. Stage II

The nurse recognizes that a client recovering from anesthesia required for surgical repair of a fractured ulna is likely to experience difficulty urinating primarily because of: A. The impaired cognitive state the client will experience as the effects of the anesthesia wear off B. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder C. The length of time the client was under the effects of general anesthesia required for the surgical procedure D. The decreased volume of orally ingested fluids before, during, and after the surgical procedure

B. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder

When receiving a report at the beginning of your shift, you learn that your assigned client has a surgical incision that is healing by primary intention. You know that your client's incision is: A. Going to take a little longer than usual to heal. B. Well approximated, with minimal or no drainage. C. Going to have more scarring than most incisions. D. Draining some serosanguineous drainage.

B. Well approximated, with minimal or no

A 43 year old client is scheduled to have a gastrectomy. Which of the following is a major pre-op concern? A. the client's brother had a tonsillectomy at age 11 B. the client smokes a pack of cigarettes a day C. the client has an IV infusion D. the client has a history of employment as a computer programmer

B. the client smokes a pack of cigarettes a day

When asked what the role of the skin is in maintaining homeostasis, the answer that reflects the greatest insight is: A. "Our body needs vitamin D, and without healthy skin we cannot utilize it into a form we can use." B. "Without skin we would not be able to enjoy the sense of touch that is so important to us as humans." C. "The skin is a barrier that is really quite good at keeping disease-causing pathogens from getting into our body." D. "It is the pain with its pain receptors that alert us to danger so that we can take appropriate action in order to be safe."

C. "The skin is a barrier that is really quite good at keeping disease-causing pathogens from getting into our body."

Which of the following statements made by the nurse shows the greatest insight into the need to manage the risk factors that contribute to the formation of a pressure ulcer? A. "Her diet needs to include more protein and less sugary foods." B. "She needs to be moved more gently and with attention to her skin." C. "We need to decrease the time she spends with the weight of her body resting on her hip" D. "The urinary incontinency makes the risk for developing a pressure ulcer so much greater for her."

C. "We need to decrease the time she spends with the weight of her body resting on her hip"

When calculating the daily intake and output, the nurse anticipates that the urinary output for an average adult should be: A. 800 to 1000 mL/day B. 1000 to 1200 mL/day C. 1500 to 1600 mL/day D. 2000 to 2300 mL/day

C. 1500 to 1600 mL/day

The nurse is working in a post-op care unit in an ambulatory surgery center. Of the following clients that have come to have surgery, the cline at the greatest risk during surgery is: A. 78 yo taking analgesic agent B. 43 yo taking anti- hypertensive agent C. 27 yo taking anticoagulant agent D. 10 yo taking an abx agent

C. 27 yo taking anticoagulant agent

Which of the following actions by the nurse would indicate the need for remedial education in the removal of an indwelling catheter? A. Draping the female client between the thighs B. Obtaining a specimen before removal C. Cutting the catheter to deflate the balloon D. Checking the client's output for 24 hours after removal

C. Cutting the catheter to deflate the balloon

The perioperative nurse realizes that the most effective means of evaluating the client's understanding of previous teaching is to: A. Provide written material on the subject to be reviewed after discharge B. Reinforce the material with family as the procedure is being performed C. Discuss it with the client and family in the immediate preoperative period D. Offer to answer any questions that the client or family have just before discharge

C. Discuss it with the client and family in the immediate preoperative period

The nurse is assessing the pressure ulcer of a 68-year-old female client. Which of the following would indicate to the nurse that healing is taking place? A. Eschar B. Slough C. Granulation tissue D. Exudate

C. Granulation tissue

For a client who has a muscle sprain, localized hemorrhage, or hematoma, application of which of the following helps to prevent edema formation, control bleeding, and anesthetize the body part? A. Absorptive diaper B. Binder C. Ice bag D. Elastic bandage

C. Ice bag

A 48-year-old male client with a history of chronic obstructive pulmonary disease (COPD) is scheduled for an inguinal hernia repair. The nurse instructs that client that he can expect the health care provider to order which of the following tests before surgery? A. Human immunodeficiency virus (HIV) antibody B. Prolactin level C. Pulmonary function test D. Glucose tolerance test

C. Pulmonary function test

Granulated tissue is best described as A. Soft, yellow, and stringy B. Black, hard, and necrotic C. Red, moist, and vascular-rich D. Yellow, spongy, and sinewy

C. Red, moist, and vascular-rich

Several instruments are available for assessing clients who are at high risk for developing a pressure ulcer. To identify the risk, what areas should you assess? A. Physical condition, mental condition, activity, mobility, and incontinence B. Infection, hemorrhage, dehiscence, evisceration, and fistulas C. Sensory perception, moisture, activity, mobility, nutrition, friction, and shear

C. Sensory perception, moisture, activity, mobility, nutrition, friction, and shear

When cleaning a wound, the nurse should: A. Wash over the wound twice and discard that swab B. Move from the outer region of the wound toward the center C. Start at the drainage site and move outward with circular motions D. Use an antiseptic solution followed by a normal saline rinse

C. Start at the drainage site and move outward with circular motions

The nurse is very busy and needs to delegate some tasks to the nursing assistive personnel (NAP). Which of the following would be the most appropriate task to delegate? A. Postoperative client teaching B. Demonstrating postoperative exercises C. Transporting the preoperative client from the unit to the holding area D. Reviewing the preoperative assessment to make sure that the client's vital signs have been documented

C. Transporting the preoperative client from the unit to the holding area

The autolytic, mechanical, chemical, and surgical methods that are often used during wound management are all methods of accomplishing what? A. Wound dressing B. Wound cleansing C. Wound débridement D. Stimulation of growth factors

C. Wound débridement

Following abdominal surgery, the nurse suspects that the client may be having internal bleeding. Which of the following findings is indicative of this complication? A. increased blood pressure B. incisional pain C. abdominal distension D. increased urinary output

C. abdominal distension

A client who has type 2 diabetes is scheduled for the removal of a skin lesion on his right shoulder at an ambulatory surgery unit. The nursing diagnosis the client is at greatest risk for postoperatively is: A. Risk for injury B. Risk for infection C. Impaired wound healing D. Imbalanced nutrition: less than body requirements

C. impaired wound healing

The client tells the nurse that "blowing into this tube thing (incentive spirometer) is a ridiculous waste of time." the nurse explains that the specific purpose of the therapy is to: A. directly remove excess secretions from the lungs B. increase pulmonary circuluation C. promote lung expansion D. stimulate the cough reflex

C. promote lung expansion

Pressure ulcers form primarily as a result of: A. nitrogen buildup in the underlying tissues B. prolonged illness or disease C. tissue ischemia D. poor nutrition

C. tissue ischemia

First aid for wounds

- establish hemostasis (control bleeding; allow puncture wounds to bleed, do not remove penetrating object) - control bleeding by applying direct pressure with sterile/clean dressing - remove contaminants that serve as sources of infection - normal saline (preferred agent of cleaning)

Which of the following items are used to perform wound care irrigation? Select all that apply. 1. Clean gloves 2. Sterile gloves 3. Refrigerated irrigating solution 4. 60-mL syringe

1, 2, and 4; To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be at room or body temperature-- certainly not refrigerated.

When is application of a warm compress to an ankle muscle sprain indicated? (select all that apply) 1. to relieve edema 2. to reduce shivering 3. to improve blood flow to an injured part 4. to protect body prominences from pressure ulcers 5. to immobilize the area

1, 3

Braden scale

Risk assessment; prediction and prevention of pressure ulcers - based on sensory perception, moisture, activity, mobility, nutrition, friction and shear

Which of the following pressure ulcers has the worse prognosis? A. Full-thickness loss of skin with the epidermis and dermis gone and damage to or necrosis of subcutaneous tissues. Damage extends down to but not through the underlying fascia. Subcutaneous fat may be visible, but muscle, tendon, or bone is not seen. Slough may be present but does not hinder estimation of the extent of tissue loss. Tunneling or undermining may be present. B. Skin is intact with an area of nonblanching erythema. This is usually over a bony prominence. C. Partial-thickness skin loss with loss of the epidermis and some of the dermis. It appears as a shallow ulcer with a red-pink color. No slough or necrotic tissue is present in the base. It may also appear as an enclosed or open serum-filled blister. D. Full-thickness loss of skin with extensive destruction, tissue necrosis, and damage to bone, muscle, or other supporting structures that are exposed.

D. Full-thickness loss of skin with extensive destruction, tissue necrosis, and damage to bone, muscle, or other supporting structures that are exposed.

Which of the following statements made by the nurse shows the most informed understanding of the role of family in the client's postoperative recovery? A. "The family will be the ones you will be dealing with regarding postoperative needs." B. "When the family is more relaxed about caring for the client, the client is more relaxed." C. "The more the family understands what to expect during recovery, the more comfortable they are in caring for the client." D. "Teaching the family what they need to know before the surgery will maximize their effectiveness regarding the client's postoperative care."

D. "Teaching the family what they need to know before the surgery will maximize their effectiveness regarding the client's postoperative care."

Which of the following is the best description of a hydrocolloid dressing? A. A dressing containing a seaweed derivative that is highly absorptive. B. A dressing containing a débriding enzyme that is used to remove necrotic tissue. C. Premoistened gauze placed over a granulating wound. D. A dressing that forms a gel which interacts with the wound surface.

D. A dressing that forms a gel which interacts with the wound surface.

The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen? A. Apply sterile gloves for the procedure B. Restrict fluids before the specimen collection C. Place the specimen in a clean urinalysis container. D. Collect the specimen after the initial stream of urine has passed.

D. Collect the specimen after the initial stream of urine has passed.

Postoperatively a client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the nurse sees that the sutures are open and that pieces of small bowel are visible at the bottom of the now opened wound. The correct intervention would be to: A. Cover the area with sterile gauze; place a tight binder over the areas; ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly. B. Place several cold packs over the area, with care taken to protect the skin around the wound. C. Allow the area to be exposed to air until all drainage has stopped. D. Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.

D. Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.

The nurse is concerned that the client's midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication? A. Administering antibiotics to prevent infection B. Using appropriate sterile technique when changing the dressing C. Keeping sterile towels and extra dressing supplies near the client's bed D. Placing a pillow over the incision site when the client is deep breathing or coughing

D. Placing a pillow over the incision site when the client is deep breathing or coughing

Urinary elimination may be altered with different pathophysiological conditions. For the client with diabetes mellitus, the nurse anticipates that an initial urinary sign or symptom will be: A. Urgency B. Dysuria C. Hematuria D. Polyuria

D. Polyuria

The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? A. Specific gravity of 1.03 B. Urine pH of 5.0 C. Absence of protein D. Presence of glucose

D. Presence of glucose

When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating: A. Sensitive skin that calls for the use of special bed linen B. A stage III pressure ulcer needing the appropriate dressing C. A local skin infection requiring antibiotics D. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area

D. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area

A 92 yo client is scheduled for a colectomy. Which normal physiological change accompanies aging process increases this client's risk for surgery? A. an increased tactile sensation B. an increased metabolic rate C. relaxation of arterial walls D. reduced glomerular filtration rate

D. Reduced glomerular filtration rate

Which of the following best describes the primary nursing role regarding a client's consent to surgery immediately before surgery? A. Explaining the procedure to the client in a fashion that is easily understood B. Placing the signed consent in the client's medical record C. Ensuring that the client understands the possible risks of the procedure before signing the consent D. Reviewing the client's surgical consent as a part of the routine preoperative checklist

D. Reviewing the client's surgical consent as a part of the routine preoperative checklist

A 64-year-old male client has been scheduled to undergo surgery for a total knee replacement. The client would like to be able to use his own blood for the surgery, if needed. The nurse explains that there are several advantages to the client's having an autologous infusion, but there are some drawbacks as well. Which of the following would be considered a drawback to an autologous infusion? A. The client has a decreased risk for contracting HIV. B. There is a decreased risk for infection. C. The client has less risk for a transfusion reaction. D. The client may have a decreased hemoglobin and hematocrit level on the day of surgery.

D. The client may have a decreased hemoglobin and hematocrit level on the day of surgery.

An obese client is admitted for abdominal surgery. The nurse recognizes that the client is more susceptible to the post-op complication of : A. anemia B. seizures C. protein loss D. dehiscence

D. dehiscence

The client had surgery in the morning that involved the right femoral artery. To assess the client's circulation status to the right leg, the nurse will make sure to check the pulse at the: A. Radial artery B. Ulnar artery C. Brachial artery D. Dorsalis pedis artery

D. dorsalis pedis artery

The client asks the nurse the purpose of having medications (Demerol and Vistaril) given before surgery. The nurse should inform the client that these particular medications: A. reduce properative fear B. promote emptying of the stomach C. reduce body secretions D. ease induction of anesthesia

D. ease induction of anesthesia

The nurse is evaluating the outcome "client describes surgical procedures and post-op treatment" and determines that the client has not achieved this outcome. The nurse should: A. obtain the consent, because this is expected with preoperative anxiety B. teach the client all about the procedure C. ask the unit manager to assist with a teaching plan D. inform the surgeon so that information can be provided

D. inform the surgeon so that information can be provided

The client is scheduled for abdominal surgery and has just received the pre-operative medications. the nurse should: A. keep the client quiet B. obtain consent C. prepare the skin at the surgical site D. place the side rails up on the bed or stretches

D. place the side rails up on the bed or stretches

The female client on the surgical unit is being prepared for abdominal surgery with general anesthesia. In preparing this client for surgery, the nurse should: A. remove her hearing aid before transport to the operating room B. provide her with sips of water for a dry mouth C. leave all her jewelry intact D. remove all her make up and nail polish

D. remove all her make up and nail polish

stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

Thirty minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that: 1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation) 2. It will be acceptable to leave the pad in place for another thirty minutes

1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation); The heating pads need to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect resulting in vasoconstriction. Lowering the temperature, but still delivering heat -dry or moist- will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.

Assessment of pressure ulcers

baseline assessment and continual assessment predictive measures mobility (effects of impaired mobility) nutritional status body fluids pain (if adequate, increases willingness)

Hemorrhage (complications of wound healing)

bleeding from a wound site - normal during and immediately after initial trauma

Puncture wound

bleeds in relation to the depth and size of the wound

Which condition places the client at the greatest risk for developing an infection? 1. Implantation of a prosthetic device 2. Burns over more than 20% of the body 3. Presence of an indwelling urinary catheter 4. More than 2 puncture sites from laparoscopic surgery

2. Burns over more than 20% of the body, Burns more than 20% of the client's total body surface are generally considered major burn injuries. When the skin is damaged by a burn the underlying tissue is left unprotected and the individual is at risk for infection. The greater the extent and deeper the depth of the burn, the higher the risk is for infection. Prosthetic devices are surgically implanted under sterile conditions to minimize risk of infection. Indwelling urinary catheters are implanted under sterile conditions and are considered closed systems where sterile technique is maintained. Laparoscopic surgery is also performed using sterile technique.

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is: 1. Risk for Impaired Skin Integrity 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection

2. Impaired Skin Integrity; The client has an actual impairment of the skin due to the rash and the scratching so is no longer "at risk". Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected.

What does the Braden scale evaluate? 1. skin integrity at bony prominences, including any wounds 2. risk factors that place the patient at risk for skin breakdown 3. the amount of repositioning that the patient can tolerate 4. the factors that place a patient at risk for poor healing

2. risk factors that place the patient at risk for skin breakdown

Unstagable ulcer

full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough and or/eschar in the wound bed

Stage 4 pressure ulcer

full thickness tissue loss with exposed bone, muscle or tendon

stage 3 pressure ulcer

full thickness tissue loss with visible fat

Stage 3 pressure ulcer

full-thickness tissue loss with visible fat

Hydrogel dressing

gauze or sheet dressings impregnated with water or glycerin-based amorphous gel - soothing and can reduce wound pain - provides a moist environment - debrides necrotic tissue - does not adhere to wound base and is easy to remove

partial thickness wound repair

heal via the inflammatory response, epithelium proliferation and migration with reestablishment of epidermal layers

Full-thickness wound repair

heals via inflammatory response, proliferation and remodeling 1. hemostasis (fibrin) control blood loss, establish bacterial control and seal defect that results when an injury occurs ;clots form fibrin matrix that later provide framework for cellular repair 2. inflammatory stage- damaged tissue and mast cells secrete histamine --> vasodilation of surrounding capillaries and exudation of serum and WBC into damaged tissue 3. proliferative stage- appearance of new blood vessels; filling of the wound with granulation tissue, contraction of the wound and resurfacing of the wound by epithelialization 4. remodeling/maturing

Cold therapy

initially diminishes swelling and pain prolonged exposure --> reflex vasodilation --> tissue ischemia

Stage 1 pressure ulcer

intact skin with non-blanchable redness

Stage 1 pressure ulcer

intact skin with nonblanchable redness

The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the client's skin integrity? a) Encouraging the client to perform pelvic muscle training exercises several times a day b) Keeping the head of the bed in a high-Fowler's position to increase circulation c) Having the client sit up in a chair for 4-hour intervals d) Keeping a written schedule of turning and positioning

d) Keeping a written schedule of turning and positioning

The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: a) Stage III b) Stage I c) Stage IV d) Stage II

d) Stage II

Hematoma (complications of wound healing)

localized collection of blood underneath the tissues

Pressure ulcer

localized injury to the skin and underlying tissue, usually over bony prominence - results from pressure in combination with shear and/or friction

Wound healing

occurs by primary or secondary intention primary intention - when the edges are approximated ex: surgical incision (wound is closed) secondary intention - when the wound heals with scar tissue ex: burn, pressure ulcer (wound is left open)

Dehiscence (complications of wound healing)

partial or total separation of wound layers

Stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis or both

stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both

Heat therapy

periodic removal and reapplication - restore vasodilation if left too long, can damage epithelial cells, cause redness, localized tenderness and blistering

Gauze dressing

dry or moist; - especially useful in wounds to wick away the wound exudate - 4x4 most common size - can be saturated with solutions to clean and pack a wound

Dermis-

provides tensile strength, mechanical support, and protection to underlying muscles, bones and organs made of collagen, blood vessels and nerves

Granulation tissue

red, moist tissue composed of new blood vessels - presence indicates progression toward healing

Surgical debridement

removal of devitalized tissue by using a scalpel, scissors or other sharp instruments

Film dressing

secondary dressing for autolytic debridement of small wounds - adheres to undamaged skin -serves as a barrier to external fluids and bacteria but still allows wound surface to breathe b/c 02 passes through the transparent dressing -promotes moist environment that speeds epithelial cell growth - can be removed w/o damaging underlying tissues - permits viewing a wound - does not require a secondary dressing

Laceration

sometimes bleeds profusely, depends n the depth and location of the wound

Epidermis-

stratum corneum - outermost layer with dead keratinized cells; protects underlying cells and tissues from dehydration and prevents entrance of certain chemical agents - allows evaporation of water from the skin and permits absorption of certain topical medications

Abrasion

superficial, with little bleeding partial-thickness wound

Autolytic debridement

synthetic dressings over a wound to allow the eschar to be self- digested by the action of enzymes that are present in wound fluids

Eschar

tan, brown or black - black or brown necrotic tissue

Shear

the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance between the patient and a surface

Friction

the force of two surfaces moving across one another, such as mechanical force exerted when the body is dragged across another surface

blanching occurs when

the normal red tones of the skin are absent does not occur in dark-skinned patients

Irrigation

to remove exudates, using sterile technique with 35 mL syringe and 19 gauge needle - constant low- pressure flow; cleans wound of exudates and debris

Evisceration (complications of wound healing)

total separation of wound layers

Chemical debridement

use topical enzymes to induce changes in substrate resulting in the breakage of necrotic tissue. - the preparation digests or dissolves the tissue - need a health care provider's order

Name three important dimensions to consistently measure to determine wound healing.

width, length and depth

Mechanical debridement (acute care)

wound irritation ( high-pressure irrigation , pulsatile high-pressure lavage and whirlpool treatments)

Slough

yellow, tan, gray, green or brown - stringy substance attached to wound bed, must be removed by a skilled clinician for would to heal

Factors influencing pressure ulcer formation and wound healing

Nutrition tissue perfusion infection (pus, change in color, odor, volume, or redness of tissue; fever, and pain) age psychosocial impact of wounds

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard and adherent to the wound edge. what is the correct stage for this patient's ulcer? 1. stage 2 2. stage 4 3. unstageable 4. suspected deep-tissue damage

3. unstageable

What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. use slow, continuous pressure to irrigate the wound 2. attach 19-gauge angiocatheter to syringe 3. fill syringe with irrigation fluid 4. place waterproof bag near bed 5. position angiocatheter over wound

4,3,2,5,1

The nurse assesses the patient's pressure injury risk using the Braden Scale. What does the nurse use to quantify the sensory perception component of the tool? A. Degree of physical activity B. Level of pain using the numeric scale C. Ability to change and control body position in bed D. Degree to which skin is exposed to moisture

B. Level of pain using the numeric scale

A client scheduled for an ambulatory surgery procedure requiring anesthetics arrives with a low-grade fever and a productive cough. The postponement of the procedure is most likely a result of the: A. Client's increased risk for a respiratory tract infection B. Possibility of a respiratory complication during anesthesia C. Increased risk for the client's infecting staff and other clients D. Client's impaired resistance as a result of a respiratory tract infection

B. Possibility of a respiratory complication during anesthesia

Serous drainage from a wound is defined as A. Fresh bleeding B. Thick and yellow drainage C. Clear, watery plasma D. Beige to brown and foul-smelling drainage

C. Clear, watery plasma

A client has a healing abdominal wound. The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing? A. Primary intention B. Inflammatory phase C. Proliferative phase D. Secondary intention

C. Proliferative phase

There are three phases of wound healing. The nurse observes granulation tissue in a client's pressure ulcer. What phase of wound healing is represented by granulation tissue? A. Maturation phase B. Hemostasis phase C. Proliferative phase D. Inflammatory phase

C. Proliferative phase

The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is: A. A reduced skin elasticity is common in the older adult B. The attachment between the epidermis and dermis is weaker C. The older client has less subcutaneous padding on the elbows D. Older adults have a poor diet that increases risk for pressure ulcers

C. The older client has less subcutaneous padding on the elbows

The nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest for surgical wounds? A. 7 days after surgery, when the client is more active. B. Between 48 and 60 hours after surgery. C. Between 60 and 72 hours after surgery. D. During the first 24 to 48 hours after surgery.

D. During the first 24 to 48 hours after surgery.

Which nursing entry is most complete in describing a client's wound? A. Wound appears to be healing well. Dressing dry and intact. B. Wound well approximated with minimal drainage. C. Drainage size of quarter; wound pink, 4 × 4s applied. D. Incisional edges approximated without redness or drainage; two 4 × 4s applied.

D. Incisional edges approximated without redness or drainage; two 4 × 4s applied.

The nurse is planning a program on wound healing and includes information that smoking influences healing by: A. Suppressing protein synthesis B. Creating increased tissue fragility C. Depressing bone marrow function D. Reducing functional hemoglobin in the blood

D. Reducing functional hemoglobin in the blood

Layers of skin

Epidermis Dermis

Purpose of dressings

- protect a wound from microorganism contamination - aid in hemostasis - promote healing by absorbing drainage and debrideing a wound - support or splint the wound site - protect patient from seeing the wound - promote thermal insulation of the wound surface

Evaluation of wound

- was the etiology of skin impairment addresses? Were pressure, friction, shear, and moisture components identified; and did the plan of care decrease contribution of these components? - was wound healing supported by providing the wound base with a moist protected environment? - were issues such as nutrition assessed and a plan of care developed to provide patient with proper calories to support healing?

Heat is contraindicated:

- for areas of active bleeding - for an acute localized inflammation - over a large area if patient has cardiovascular problems

Cold contraindicated:

- if site or injury is edematous - in the presence of neuropathy - if the patient is shivering - if the patient had impaired circulation

A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention? 1. Cut in the skin from a kitchen knife 2. Excoriated perineal area 3. Abrasion of the skin 4. Pressure ulcer

1. Cut in the skin from a kitchen knife; A cut in the skin by a sharp instrument with minimal tissue loss can heal by primary intention when the wound edges are lightly pulled together (approximated). Excoriations, abrasions, and pressure ulcers heal by secondary, not primary. Secondary intention healing occurs when wound edges are not approximated because of full-thickness tissue loss; the wound is left open until it fills with new tissue. Abrasions and excoriations are injuries to the surface of the skin.