Chapter 28 Wound Care

The status of the client's tetanus immunization

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?

assessing the wound for active bleeding

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

gauze

The nurse has collected blood from a client for laboratory analysis. Which dressing will the nurse select to cover the site from which the blood was drawn?

Apply saline solution-moistened gauze over the protruding area.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

an obese woman with a history of type 1 diabetes

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

Blood clotting is initiated and WBCs move into the wound.

What are the two major processes involved in the inflammatory phase of wound healing?

False

Dehiscence is the softening of tissue due to excessive moisture

stage 3 pressure injury

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?

"Do not douche for 24-48 hours before the procedure."

A client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment?

surgical incision

A group of nursing students is reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which as healing by primary intention?

removing dead or infected tissue to promote wound healing

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?

primary intention

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

applying pads to the bony prominences of residents who have impaired mobility

A nurse at an extended care facility is conducting an in-service for care staff on the prevention of pressure ulcers. Which preventive measures should the nurse recommend?

a separation of skin and tissue in which the edges are torn and irregular

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record?

stage III

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

use pillows to maintain a side-lying position as needed

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

assisting the client in moving to prevent strain on the suture line

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

The wound base appears swollen and red, with yellow purulent drainage, and the client's oral temperature is 99°F (37.2° C).

A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate an infection?

period during which the wound undergoes changes and maturation

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?

65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest

A nurse is caring for clients on a medical-surgical unit. On the basis of known risk factors, the nurse understands that which client has the highest risk for developing a pressure injury?

"I will restrict my diet to fats and carbohydrates."

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?

contusion

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?

notify the health care provider and prepare for surgery

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

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

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?

prevention of swelling

The nurse educator on a hospital's acute medical unit has created a document encouraging nurses to use cold applications when appropriate to clients' plans of care. What benefits of cold application should the educator cite?

transparent film

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?

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

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?

"It provides a way to remove drainage and blood from the surgical wound."

The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

proliferation phase

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

covering the wound area with sterile towels moistened with sterile 0.9% saline.

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and:

shearing force

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of pressure injuries. What is the name given to the factor responsible for this risk?

reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization

Which describes the proliferative phase of the wound healing process?

stage 2 pressure injury

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound?