Skin Integrity and Wound Care
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? "I can let this stay on my ankle an hour at a time." "I will put a layer of cloth between my skin and the ice pack." "I should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy."
"I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.
The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. Use an aquathermia pad during the treatment to create heat and circulate the water. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles.
Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Explanation: Warm soaks and dressing changes can be painful for clients with abscesses. Often, nurses will premedicate with pain medications, often opioids, 20 to 30 minutes prior to make the treatments more comfortable for clients. Increasing client comfort can increase effectiveness by allowing the nurse time to adequately perform the treatment, assess the wound, and apply the new dressing. Aquathermia pads are used to promote wound healing, but they are not used simultaneously with water therapies. Dangling the legs and ambulating will not increase comfort.
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? Administer the prescribed analgesic. Assess the client's wound and vital signs. Document the pain and vital signs. Notify the health care provider of the pain.
Assess the client's wound and vital signs. Explanation: First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.
A child is brought to the clinic by a parent who states that the child has been at camp. The child has a rash on the face, arms, and legs and says that it itches severely. How will the nurse document the assessment findings? Superficial contusion accompanied by pruritus Diffuse fungal infection accompanied by pruritus Superficial abscess accompanied by pruritus Diffuse dermatitis accompanied by pruritus
Diffuse dermatitis accompanied by pruritus Explanation: The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching. A contusion is a closed wound with bleeding in underlying tissues from a blunt blow. Fungal infections do not cause a rash or itching. An abscess is a localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed.
A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. Decreased radial pulse No finger numbness or tingling Fingers with quick capillary refill Warm hand Cyanosis
Fingers with quick capillary refill Warm hand No finger numbness or tingling
A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? Do not attempt to remove the sutures because the wound needs more time to heal. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Carefully pick the crusts off the sutures with the forceps before removing them.
Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.
A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain? The status of the client's tetanus immunization Staging the wound for assessment If there is contamination of dirt and debris The event leading up to the trauma
The status of the client's tetanus immunization Explanation: Staging the wound is only done with pressure injuries. The presence of dirt or debris is something that will need to be addressed, but not the most important assessment. Understanding how the client stepped on the nail will need to be noted and is a possible educational opportunity for prevention, but it is not the most important assessment concern. Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defense against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? an otic curette a small plastic ruler a sterile, flexible applicator moistened with saline a sterile tongue blade lubricated with water soluble gel
a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.
A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery? period during which new cells fill and seal a wound period during which the wound undergoes changes and maturation physiologic defense immediately after the tissue injury process by which damaged cells recover and reestablish normal function
period during which the wound undergoes changes and maturation Explanation: The remodeling phase can be described as the period during which the wound undergoes changes and maturation. The remodeling phase follows the proliferative phase and may last 6 months to 2 years. The inflammatory phase is the physiologic defense immediately after tissue injury. The proliferation phase is the period during which new cells fill and seal the wound. Resolution is the process by which damaged cells recover and reestablish normal function. This forms part of the proliferation phase.
