Skin integrity and wound healing davis edge

Serous drainage

Serous drainage is a clear or a straw-colored fluid; it does not contain pink or red color.

Sanguineous drainage

bloody drainage from capillaries No pink

A client presents to the emergency room after sustaining an injury where a nail entered the hand. Which questions should the nurse ask the client to determine if a tetanus shot is needed? Select all that apply. 1. "Do you have any allergies to tetanus toxin?" 2. "Have you had a tetanus shot in the past 2 years?" 3. "Was the nail rusty or was it brand new out of the box?" 4. "Have you sustained a puncture wound like this before?" 5. "Can you tell me your current pain level on a scale of 1 to 10?"

1. "Do you have any allergies to tetanus toxin?" 3. "Was the nail rusty or was it brand new out of the box?"

A client has been brought in from a motorcycle accident in which he or she has suffered deep track-like injuries with debris that can only partially be removed. What type of dressing should be applied to this client's wounds? 1. Alginate 2. Absorbent 3. Antimicrobial 4. Collagen

1. Alginate Alginates facilitate autolytic debridement and are ideal for wounds that are deep, track-like, or tunnel-like.

What are primary causes of maceration? Select all that apply. 1. Fever 2. Incontinence 3. Bowel incontinence 4. Infection 5. Tanning

1. Fever 2. Incontinence

What is an appropriate nursing intervention to prevent dehiscence in an obese client who is recovering from abdominal surgery? 1. Maintain bedrest with the head of the bed elevated at 20° and the knees flexed. 2. Identify the risk for impaired tissue integrity. 3. The wound will heal by May 1, as evidenced by a progressive decrease in the size of the wound. 4. Provide client education on wound care.

1. Maintain bedrest with the head of the bed elevated at 20° and the knees flexed. Maintaining bedrest with elevation and knee flexion is an appropriate intervention that will help reduce the risk of dehiscence.

While reviewing a client's lab work, a nurse notices blood serum levels are low. For what potential risk should the nurse monitor? 1. Pressure injuries 2. Infection 3. Inflammation 4. Altered coagulation

1. Pressure injuries Delayed wound healing and pressure injuries are seen in clients with low blood serum levels that indicate limited nutritional stores.

The nurse is supervising a student nurse who is managing the care of a client who has lower extremity edema related to an arterial skin ulcer. Which action made by the nursing student requires correction? 1. Elevating the lower extremity 2. Applying compression stockings 3. Instructing about smoking cessation 4. Administering pain medications before dressing change

2. Applying compression stockings

Which tissue found in the wound bed is described as dry, thick, and leathery, and may be black, brown, or gray? 1. Slough 2. Eschar 3. Granulation 4. Nongranulating

2. Eschar

The nurse is working with a client with low total protein and serum albumin levels. The client presents with bilateral pitting lower extremity edema. Which education should the nurse provide to decrease and prevent edema formation? 1. Increase cholesterol in the diet. 2. Increase protein foods in the diet. 3. Increase vitamin C and zinc content. 4. Increase fluid intake during the day.

2. Increase protein foods in the diet. Edema forms from changes in oncotic pressure. When albumin is deficient, fluid leaks out of the capillaries into the interstitial spaces, causing edema and skin breakdown. If the client increases protein in the diet, it should draw fluid back into the vascular compartment and decrease edema.

The nurse is documenting wound progress for a client and notes that there is pearly pink tissue in the wound bed as well as granulation tissue. It has decreased in size over the past 4 weeks. Which type of healing should the nurse document is occurring? 1. Primary intention 2. Secondary intention 3. Tertiary intention 4. Inflammatory phase

2. Secondary intention This wound is healing by secondary intention, as there is granulation and epithelial tissue in the wound bed. The wound is healing from the inside out.

A nurse notices a wound that has developed on the lower back of a client that has adipose tissue exposed with full-thickness skin loss. What stage is this pressure injury? 1. 1 2. 2 3. 3 4. 4

3. 3

The nurse is educating a client on performing his or her own wound care upon discharge. The wound bed has some necrotic tissue in it. What should the nurse include in the instructions? 1. Dry it. 2. Clean it. 3. Don't scrub it. 4. Leave it open to air.

3. Don't scrub it. The nurse would instruct the client to not scrub the wound bed of a necrotic wound.

The nurse is caring for a client who is deficient in protein and has poor skin turgor. Which skin cells would be causing this to happen? 1. Dermis cells 2. Melanocytes 3. Keratinocytes 4. Langerhans cells

3. Keratinocytes Keratinocytes are protein-containing cells that give skin its strength and elasticity. If the client is protein deficient, the lack of protein in these cells affects skin turgor.

Which phase of wound healing describes collagen fibers breaking down and remodeling? 1. Hemostasis 2. Inflammation 3. Granulation 4. Epithelialization

4. Epithelialization In epithelialization, collagen fibers are broken down and remodeled.

The nurse is reviewing laboratory results for a 55-year-old client with a venous stasis ulcer. Which result reflects the presence of chronic wound inflammation? 1. Serum albumin level 4.0 g/dL 2. White blood cell count (WBC) 8000/mm3 3. Partial thromboplastin time (PTT) 16 seconds 4. Erythrocyte sedimentation rate (ESR) 40 mm/hour

4. Erythrocyte sedimentation rate (ESR) 40 mm/hour

Which level of contamination describes a wound with bacteria in excess of 100,000 organisms per gram of tissue? 1. Clean 2. Clean-contaminated 3. Contaminated 4. Infected

4. Infected

A client presents to the clinic after falling in a parking lot and sustaining an injury. There is a break in the skin with jagged edges. There is no evidence of foreign debris in the wound. As the nurse documents the wound care, which term would the nurse use in the health record? 1. Abscess 2. Incision 3. Crushing 4. Laceration

4. Laceration A laceration is a cut in the skin when the skin and mucous membranes are torn open. It leaves a cut with jagged edges.

The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record? 1. Serous 2. Purulent 3. Sanguineous 4. Serosanguineous

4. Serosanguineous Serosanguineous drainage is a mixture of serous and sanguineous drainage that is light red or pink-tinged.

The nurse is assessing a client's risk for skin breakdown using the Braden scale. The nurse notes: The client is alert and oriented to person and is able to answer commands. The client has skin that is occasionally moist due to urinary incontinence. The client stays in the chair most of the day, needs assistance to get up. The client is unable to reposition on his or her own and frequently needs to be pulled up in bed. The client eats about 50% of breakfast and dinner but frequently skips lunch. What would the nurse rate as the client's Braden score?

According to the Braden scale, the client would receive 3 points for being able to answer commands, 3 points for occasional moisture, 2 points for being chairfast, 2 points for limited mobility, 3 points for adequate nutrition, and 1 point for frequently sliding down in bed. This equals 14 points.

Tertiary intention

An example of wound healing by tertiary intention would occur after secondary intention. When a secondary intention wound heals enough, it can be surgically closed by tertiary intention.

Place in order the steps for obtaining a sterile wound culture.

The nurse would gather the needed supplies and don nonsterile gloves. After removing the old dressing, the nurse would place an emesis basin under the base of the wound and then irrigate the wound using a 35-mL syringe with a 19-gauge angiocatheter. This prevents too much psi that results from using a smaller syringe. The nurse would then twist the top of the aerobic culturette tube to loosen the swab and press the swab against a beefy red portion of the wound bed. The next step is to carefully insert the swab into the aerobic culturette container and then crush the bottom of the ampule to activate the culture medium. The nurse should then label the tube with the name, time, date, and source and send it to the lab.

incision

formed from a surgical procedure

evisceration

protrusion of viscera through an incision

maceration

softening of tissue by soaking

purulent drainage

thick green, yellow, or brown drainage

crushing injury

wound caused by force with a minimal break in the skin

What is missing from the documentation regarding the emptying of drainage from a wound? 03/12/20160750Hemovac drained serosangiuneous fluid over 12 hours. No odor or purulent material noted at drainage site...........................N. Signature RN 1. Amount drained 2. a.m. or p.m. 3. Description of color of drainage site 4. Materials used

1. Amount drained

A client reports to the nurse that there is drainage leaking around the Jackson-Pratt (JP) drain. The nurse notices the JP drain bulb is empty and the dressing is saturated with serosanguineous drainage. What should the nurse do first? 1. Check the JP drain tubing for kinks. 2. Compress the bulb and close the lid. 3. Remove the JP drain from the abdomen. 4. Notify the primary health-care provider.

1. Check the JP drain tubing for kinks.

When checking on a postoperative client, the nurse notices evisceration. What should immediately be done? 1. Cover the wound with sterile towels or dressings soaked in sterile saline solution. 2. Have the client stay in bed with knees bent to minimize strain on the incision. 3. Notify the surgeon. 4. Prepare the client for surgery.

1. Cover the wound with sterile towels or dressings soaked in sterile saline solution. Immediately covering the wound prevents the organs from drying out and becoming contaminated with environmental bacteria.

The nurse is assessing the skin of a client and notes the area around the buttocks is reddened and macerated. Which factors may have contributed to this finding? Select all that apply. 1. Fever 2. Nausea and vomiting 3. Urinary incontinence 4. Shearing and friction 5. Continuous pressure

1. Fever 3. Urinary incontinence

What should the nurse monitor in a client who is taking blood pressure medication? 1. Ischemia 2. Inhibited wound healing 3. Hematoma 4. Xerosis

1. Ischemia Antihypertensives decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia.

A client has a wound that has been allowed to heal through secondary intention due to excessive loss of tissue. The physician is planning to suture the tissue together when the wound is ready. What should the nurse be monitoring to determine the readiness for delayed primary closure? 1. No evidence of edema, infection, or foreign matter 2.Small pearl-like or pink areas beginning to appear 3.Epithelial and dermal cells forming new skin 4.Platelets and fibroblasts migrating into the wound

1. No evidence of edema, infection, or foreign matter

The nurse on the medical-surgical unit has noticed a client has edema. Why should the nurse address this issue in the care plan? 1. Poor oxygen diffusion to the cells can cause skin breakdown. 2. Wound healing is inhibited. 3. Pressure-related injuries occur due to loss of padding. 4. Diminished tactile sensation occurs.

1. Poor oxygen diffusion to the cells can cause skin breakdown. Reduced elasticity due to edema interferes with oxygen diffusion to the cells, which can result in skin breakdown and integrity issues.

What are the functions of the stratum corneum layer of the skin? Select all that apply. 1. Prevents water loss 2. Eliminates foreign material 3. Protects from ultraviolet light 4. Functions as a protective barrier 5. Stops chemicals from entering the body

1. Prevents water loss 4. Functions as a protective barrier 5. Stops chemicals from entering the body

Primary intention

healing occurs when the edges are well approximated and heals with minimal scarring. A surgical incision would be healing with primary intention.

laceration

is a cut in the skin when the skin and mucous membranes are torn open. It leaves a cut with jagged edges.

What skin integrity issue should the nurse be aware of when working with a client diagnosed with Alzheimer's disease? 1. Impaired cognition can lead to pressure injuries. 2. Alzheimer's clients are at a higher risk for falls. 3. Most clients with Alzheimer's are older and have xerosis. 4. Impaired cognition may interfere with communication.

1. Impaired cognition can lead to pressure injuries. Clients with cognitive disorders may not be aware of the need to reposition and thus are predisposed to increased pressure injuries.

The nurse is monitoring a wound for healing. At which stage of healing would dehiscence typically be seen? 1. Inflammatory phase 2. Maturation phase 3. Proliferative phase 4. Tertiary phase

1. Inflammatory phase Wound dehiscence is most likely to occur during the inflammatory phase, before collagen has been deposited.

The nurse is educating a client with new onset type 1 diabetes mellitus regarding microvascular and macrovascular complications. Which interventions should the nurse instruct the client to include in daily care to prevent skin breakdown? Select all that apply. 1. Inspect the feet daily. 2. Soak the feet every day. 3. Dry the feet thoroughly. 4. Wear well-fitting shoes. 5. Clip the toenails every week.

1. Inspect the feet daily. 3. Dry the feet thoroughly. 4. Wear well-fitting shoes.

Which findings would the nurse expect to find when performing wound care for a client with a venous stasis ulcer? Select all that apply. 1. Irregular wound edges 2. Wound bed beefy red 3. Periwound area reddened 4. Pain noted with ambulation 5. Loss of hair to the periwound area

1. Irregular wound edges 2. Wound bed beefy red 3. Periwound area reddened

Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of a client? Select all that apply. 1. Location of the wound 2. Length, width, and depth 3. Nutritional status of the client 4. Presence of undermining or tunneling 5. Number and type of dressing supplies used 6. Drainage amount, color, consistency, and odor

1. Location of the wound 2. Length, width, and depth 4. Presence of undermining or tunneling 6. Drainage amount, color, consistency, and odor

Which lifestyle choices can lead to alterations in skin integrity? Select all that apply. 1. Smoking 2. Tanning 3. Exercise 4. Daily bathing 5. Adequate nutrition

1. Smoking 2. Tanning

What is the primary purpose of swaddling a newborn for the first few weeks of life? 1. Thermoregulation 2. Sense of security 3. Prevent accidental scratching 4. Mimics the womb

1. Thermoregulation Skin of a newborn is thinner and thermoregulation must be facilitated by swaddling and keeping the newborn's body heat contained.

What type of chronic wound is found typically in the lower extremities and manifests as a shallow wound with irregular wound margins and a wound bed that appears "ruddy" or "beefy" red and granular? 1. Venous stasis ulcer 2. Arterial ulcer 3. Pressure injury 4. Diabetic foot ulcer

1. Venous stasis ulcer

What is one skin integrity issue that should be addressed with an older adult client that has been admitted? 1. Xerosis 2. Overactive sweat glands 3. Adult acne 4. Decreased fat deposit

1. Xerosis Xerosis is itchy, red, dry, scaly, cracked, or fissured skin that is a problem for about 85% of older adults and can be a threat to the integrity of the skin.

The nurse examines a wound on a client's hip and notes purulent drainage. The wound culture report states it has developed critical colonization. How should the nurse interpret these findings? 1. The wound culture was contaminated. 2. The bacteria have overwhelmed body defenses. 3. The microorganisms are causing harm and releasing toxins. 4. The report means there are microorganisms in the wound.

2. The bacteria have overwhelmed body defenses. Critical colonization means the wound has overwhelming bacterial presence that leads to changes in drainage, color, or odor.

abscess

localized collection of pus. The abscess does not have jagged edges.

Critical colonization

means the wound has overwhelming bacterial presence that leads to changes in drainage, color, or odor.

Serosanguineous drainage

mixture of serum and red blood cells Looks pink