Week 2 - Chapter 32: Skin Integrity and Wound Care

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? "Dehiscence is not anything that you need to worry about." "Dehiscence is the softening of tissue due to excessive moisture." "Dehiscence is a total separation of the wound with protrusion of the viscera through it." "Dehiscence is when a wound has partial or total separation of the wound layers."

"Dehiscence is when a wound has partial or total separation of the wound layers."

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? "Reinforced adhesive skin closures will hold my wound together until it heals." "I may have staples in place for a number of days." "I will not remove the staples myself." "After delivery, I will have sutures in place."

"Reinforced adhesive skin closures will hold my wound together until it heals."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? "The margins of your wound are not in direct contact." "The surgeon will leave your wound open intentionally for a period of time." "This is a complex reparative process." "Very little scar tissue will form."

"Very little scar tissue will form."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? "As soon as the infection clears, your surgeon will staple the wound closed." "Your wound will heal slowly as granulation tissue forms and fills the wound." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."

"Your wound will heal slowly as granulation tissue forms and fills the wound."

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? Local capillary pressure must be lower than external pressure. Arteries and veins must be patent and functioning well. The volume of circulating blood must be sufficient. The heart must be able to pump adequately.

Local capillary pressure must be lower than external pressure.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Puncture of the skin Tearing of a structure from its normal position Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of the skin and tissue with some type of instrument; tissue not aligned

Tearing of a structure from its normal position

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? The nurse covers the heating pad with a heavy blanket. The nurse places the heating pad under the client's neck. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. The nurse uses a safety pin to attach the pad to the bedding.

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. False True

True

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client who lies on wrinkled sheets a client who must remain on his back for long periods of time a client who lifts himself up on his elbows a client sitting in a chair who slides down

a client sitting in a chair who slides down

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? a small plastic ruler a sterile tongue blade lubricated with water soluble gel an otic curette a sterile, flexible applicator moistened with saline

a sterile, flexible applicator moistened with saline

The nurse would recognize which client as being particularly susceptible to impaired wound healing? a client whose breast reconstruction surgery required numerous incisions A client who is NPO (nothing by mouth) following bowel surgery an obese woman with a history of type 1 diabetes a man with a sedentary lifestyle and a long history of cigarette smoking

an obese woman with a history of type 1 diabetes

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

contusion

A full-thickness or third-degree burn develops a leathery covering called a(an): eschar. static. abrasion. erythema.

eschar

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? Fish Pasta salad Green beans Banana

fish

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? preventing the client from sliding in bed lubricating the area with skin oil improving the client's hydration pulling the client up from under the arms

preventing the client from sliding in bed

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? removing purulent drainage from the wound bed in order to accurately assess it removing excess drainage and wet tissue to prevent maceration of surrounding skin stimulating the wound bed to promote the growth of granulation tissue removing dead or infected tissue to promote wound healing

removing dead or infected tissue to promote wound healing

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother: to never trim the baby's nails due to susceptibility to infection. to only use cloth diapers, since disposable ones can cause eczema. that lanugo is hair of a different color that is permanent. to apply sunscreen when exposed to ultraviolet rays.

to apply sunscreen when exposed to ultraviolet rays.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity. to provide a sinus tract for drainage. to provide drainage for bile.

to provide drainage for bile.

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? hydrocolloid bandage gauze transparent

transparent

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? Braden scale Glascow scale FLACC scale Morse scale

Braden scale

Which is not considered a skin appendage? Hair Eccrine sweat glands Connective tissue Sebaceous gland

Connective tissue

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. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. 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.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a surgical incision with sutured approximated edges a large wound with considerable tissue loss allowed to heal naturally a wound left open for several days to allow edema to subside a wound healing naturally that becomes infected.

a surgical incision with sutured approximated edges

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? avulsion incision abrasion laceration

incision

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.

• "Very little scar tissue will form." • "This is a simple reparative process." • "Your wound edges are right next to each other."

A nurse is caring for a client who has recently undergone repair of a ventral hernia. What situations should the nurse assess for that may increase the risk for delay in surgical wound healing? Select all that apply.

• insufficient protein and vitamin C intake • weak tissue and muscular support due to obesity • distention of the abdomen from accumulated intestinal gas

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 should keep this on my ankle until it is numb." "I will put a layer of cloth between my skin and the ice pack." "I must wait 15 minutes between applications of cold therapy."

"I will put a layer of cloth between my skin and the ice pack."

For which client would the application of a hydrocolloid dressing be most appropriate? A client with a sunburn affecting his back and torso A client who has a partial-thickness venous ulcer with moderate drainage A client who has just undergone a cholecystectomy (gallbladder removal) A client whose surgical incision dehisced and became infected

A client who has a partial-thickness venous ulcer with moderate drainage Exp: Hydrocolloids are occlusive or semiocclusive dressings that limit exchange of oxygen between wound and environment; they are appropriate for partial- and full-thickness wounds with light to moderate drainage. A sunburn would not normally warrant this type of wound dressing and they are not used on infected wounds. Hydrocolloid dressings are not used on uncomplicated surgical incisions.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Clean the wound from the top to the bottom and from the center to outside. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Use clean technique to clean the wound. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

Clean the wound from the top to the bottom and from the center to outside. Exp: Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown A superficial partial-thickness burn, which can appear dry and leathery May vary from brown or black to cherry red or pearly white; bullae may be present Superficial, which may be pinkish or red with no blistering

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply. using sterile technique packing the wound with iodoform gauze reinserting the protruding structures and applying a pressure dressing placing the client in the low Fowler position covering the wound with a gauze moistened with normal saline

using sterile technique placing the client in the low Fowler position covering the wound with a gauze moistened with normal saline

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?

• "It allows removal of blood and drainage from the surgical wound."

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?

• "Reinforced adhesive skin closures will hold my wound together until it heals."