Chapter 31: Skin Integrity and Wound Care (Questions)

You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate? a) "Wounds heal better when a moist wound bed is maintained." b) "Allowing a scab to form would prevent us from observing the wound for signs of infection." c) "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." d) "You may be correct. I will check with your primary health care provider."

"Wounds heal better when a moist wound bed is maintained."

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler. (less)

The nurse caring for client that had abdominal surgery 12 hours ago notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? a) Change the dressing. b) Notify the wound care nurse. c) Contact the physician. d) Document the findings.

Document the findings

The nurse is caring for a client in the emergency department who cut herself while preparing dinner at her home. The nurse understands the client's wound is in which phase of the following phases of wound healing? a) Inflammatory phase b) Hemostasis phase c) Maturation phase d) Proliferation phase

Hemostasis phase

The nurse is caring for a client in the emergency department who cut herself 15 minutes ago while preparing dinner at her home. The nurse understands the client's wound is in which phase of wound healing?

Hemostasis phase Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin with other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and to release growth factors. The proliferation phase is the regenerative phase in which granulation tissue is formed. The maturation phase involves collagen remodeling. (less)

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? a) Hydrogels b) Alginates c) Hydrocolloid dressings d) Transparent films

Hydrocolloid dressings

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which of the following is not one of these factors?

Local capillary pressure must be lower than external pressure. Local capillary pressure must be higher than external pressure for adequate skin perfusion.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. 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 sutures. (less)

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 of the following statements describes this phase of wound recovery? a) Period during which the wound undergoes changes and maturation b) Process by which damaged cells recover and re-establish normal function c) Physiological defense immediately after the tissue injury d) Period during which new cells fill and seal a wound

Period during which the wound undergoes changes and maturation

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 dead or infected tissue to promote wound healing Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration. (less)

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?

There is an unintentional separation of the wound. With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together. Edema is an accumulation of fluid in the interstitial tissue. Redness or inflammation of an area as a result of dilation is erythema. (less)

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

True

A stable eschar on the heel of the foot can serve as "the body's natural (biological) cover" and should not be removed. True or False

True

The first indication that a pressure ulcer may be developing is blanching (becoming pale and white) of the skin over the area under pressure. True or False

True

What is the most accurate definition of a wound? a) a disruption in normal skin and tissue integrity b) any trauma resulting in serious damage and pain c) a change in the function of internal organs d) any injury that results in changes in nervous tissue

a disruption in normal skin and tissue integrity

The healthcare provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? a) Assess the client's mental status. b) Assess the wound for active bleeding. c) Assess the client for claustrophobia. d) Assess for the use of antihypertensives.

assess the wound for active bleeding

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which of the following modifications is most appropriate? a) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. b) Reduce the time interval between dressing changes. c) Assure that the packing material is completely saturated when placed in the wound. d) Use less packing material.

b) Reduce the time interval between dressing changes.

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 of the following actions should the nurse perform to prevent a pressure ulcer? a) Elevate the head of the bed 90 degrees. b) Place a foot board on the bed. c) Use pillows to maintain a side lying position as needed. d) Provide incontinent care every four hours as needed.

use pillows to maintain a side lying position as needed

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and unblanchable. How will the nurse categorize this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

Stage I

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which of the following statements indicates that the client understands? a) "I will alternate between positive and negative pressure every 2 hours." b) "I will squeeze the chamber and apply the cap to maintain negative pressure." c) "I will check and empty the drain every 6 hours." d) "I will apply a dressing at the end of the drain to catch any drainage."

" I will squeeze the chamber and apply the cap to maintain negative pressure."

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

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

Which teaching will the nurse provide to a caregiver about wound healing for an 85-year-old client?

"It may take twice as long as normal for the wound to heal." "Consider having a home health aide to decrease the client's stress level." "Older adults with lots of sun exposure may experience delayed healing."

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 of the following responses by the nurse is most appropriate? a) "Your wound will heal slowly as granulation tissue forms and fills the wound." b) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." c) "As soon as the infection clears, your surgeon will staple the wound closed." d) "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."

You are preparing to irrigate a patient's wound. Arrange the following steps in the correct order. 1. Carefully remove the soiled dressing. 2. Don a mask, gown, and eye protection. 3. Gently direct a stream of solution into the wound. 4. Fill the irrigation syringe with warmed irrigation solution. 5. Dry the surrounding skin with gauze dressings. 6. Don sterile gloves.

1. Don a mask, gown, and eye protection 2. Carefully remove the soiled dressing 3. Don sterile gloves 4. Fill the irrigation syringe with warmed irrigation solution 5. Gently direct a stream of solution into the wound 6. Dry the surrounding skin with gauze dressing

A nurse is caring for a client who has a Jackson-Pratt drain. Which of the following is the order in which the nurse should carry out these interventions? 1. Change dressing to drain site 2. Empty the drain chamber's contents 3. Use a gauze pad to clean the drain's outlet 4. Measure and record the character and amount of drainage 5. Change gloves 6. Fully compress the chamber and replace the cap

1. Empty the drain chamber's contents 2. Use a gauze pad to clean the drain's outlet 3. Fully compress the chamber and replace the cap 4. Measure and record the character and amount of drainage 5. Change gloves 6. Change dressing to drain site

A nurse is providing wound care for a client who has a pressure ulcer on the right buttock. Which of the following is the correct order of nursing interventions the nurse should perform during this dressing change? 1. Apply wound covering 2. Apply sterile gloves 3. Give pain medication 4. Cleanse the wound with normal saline 5.Use non sterile gloves 6. Remove old dressing

1. give pain medication 2.use nonsterile gloves 3. remove old dressing 4. apply sterile gloves 5. cleanse the wound with normal saline 6apply wound covering

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer?

65-year-old incontinent client with a hip fracture on bed rest

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 sterile, flexible applicator moistened with saline A sterile, flexible applicator is the safest implement to use. The other implements are too large, inflexible, or not sterile.

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound?

A wound that requires wound cleaning and irrigation A wound with drainage that is a beige color A wound that is characterized by oozing from the tissue covering the wound

A nursing instructor is teaching a student nurse about the layers of the skin. Which of the following layers should the student nurse understand is a potential source of energy in an undernourished client? a) Muscle layer b) Subcutaneous tissue c) Dermis d) Epidermis

Subcutaneous tissue

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Support the client from sliding in bed. Shearing force occurs when tissue layers move on each other, causing vessels to stretch as they pass through the subcutaneous tissue.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? a. The nurse works outward from the wound in lines parallel to it. b. The nurse swabs the wound from the bottom to the top. c. The nurse uses friction when cleaning the wound to loosen dead cells. d. The nurse swabs the wound with povidone-iodine to fight infection in the wound.

The nurse works outward from the wound in lines parallel to it.

Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a patient's wound? (Select all that apply.) a) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. b) Apply one dry, sterile gauze pad over the wet gauze, and then place an ABD pad over the gauze pad. c) Put on clean gloves and squeeze excess fluid from the gauze dressing before packing it tightly in the wound. d) Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. e) Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. f) Using clean technique, open the supplies and dressings and place the fine-mesh gauze into the basin, pouring the ordered solution over the mesh to saturate it.

1.Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. 2.Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. 3.Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces.

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 Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed. (less)

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 Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings do not allow the nurse to visualize the site without partially or completely removing the dressing. (less)

A nurse is caring for a client who has a 6-cm × 8-cm wound that was received in a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which of the following dressings does the nurse anticipate is best to be ordered by the primary care provider? a) Hydrogel b) Alginate c) Transparent d) Hydrocolloid

Alginate

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection. An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows. (less)

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

An obese woman with a history of type 1 diabetes

You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate? a. "Wounds heal better when a moist wound bed is maintained." b. "You may be correct. I will check with your primary health care provider." c. "Allowing a scab to form would prevent us from observing the wound for signs of infection." d. "This wound is too large for a scab to form over it, so a moist dressing is the best alternative."

Answer: a. "Wounds heal better when a moist wound bed is maintained." Rationale: A moist wound surface enhances the cellular migration necessary for tissue repair and healing.

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 of the following responses by the nurse is most appropriate? a. "Your wound will heal slowly as granulation tissue forms and fills the wound." b. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." c. "As soon as the infection clears, your surgeon will staple the wound closed." d. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."

Answer: a. "Your wound will heal slowly as granulation tissue forms and fills the wound." Rationale: There is no indication of infection. Large wounds with extensive tissue loss may not be able to be closed by primary intention.

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 oder to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? a. A transparent film. b. A dressing with a nonadherent coating. c. A gauze dressing precut halfway to fit around the IV line. d. A gauze dressing premedicated with antibiotics.

Answer: a. A transparent film. Rationale: Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings do not allow the nurse to visualize the site without partially or completely removing the dressing.

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

Answer: a. An obese woman with a history of type 1 diabetes. Rationale: Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than is smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

A nurse prepares to give a sitz bath to a client after perianal surgery. Which of the following would be most important for the nurse to do? a. Assess for rapid pulse and facial pallor. b. Encourage use of sitz bath for about an hour. c. Maintain the temperature of water at 100°F. d. Keep the feet and torso uncovered.

Answer: a. Assess for rapid pulse and facial pallor. Rationale: When giving a sitz bath, the nurse should assess the client for a rapid pulse, pale facial color, or complaints of nausea. Because heat is being applied to a large area, vasodilation can occur, causing the client to feel light-headed and faint. The temperature of the water should be 105°F to 110°F. The client's feet and upper torso should remain covered to prevent chilling. Sitz baths usually last for about 20 minutes, not an hour.

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as: a. Stage I b. Stage II c. Stage III d. Stage IV

Answer: b. Stage II Rationale: A stage II pressure ulcer involves partial thickness, loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.

Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. a. Avoid touching the wound bed, whether with gloves or forceps. b. Clean the wound from top to bottom. c. Use a sterile applicator to apply any ointment that is ordered. d. Clean from the outside of the wound to the center. e. Use a new gauze for each wipe of the wound.

Answer: a. Avoid touching the wound bed, whether with gloves or forceps. b. Clean the wound from top to bottom. c. Use a sterile applicator to apply any ointment that is ordered. e. Use a new gauze for each wipe of the wound. Rationale: Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a. Desiccation b. Evisceration c. Necrosis d. Maceration

Answer: a. Desiccation Rationale: Desiccation is localized wound dehydration. Maceration is localized wound over hydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patent's nursing care plan? a. Document the findings and continue to monitor the patient. b. Administer antipyretics, as ordered. c. Increase the frequency of assessment to every hour and notify the patient's primary care provider. d. Increase the frequency of wound care and contact the primary care provider for an antibiotic order.

Answer: a. Document the findings and continue to monitor the patient. Rationale: The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the sit of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

A home care nurse is visiting a client as a part of a regular visit. The client's daughter age 4 years falls while playing and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress to the child's knee based on the understanding that cold achieves which effect? a. Help in controlling swelling. b. Increased blood flow. c. Relief of muscle stiffness. d. Resolution of inflammation.

Answer: a. Help in controlling swelling. Rationale: A cold compress helps control swelling. It controls bleeding because it causes vasoconstriction, which decreases blood flow to the area. Heat therapies are used to increase blood flow, relieve muscular pain and stiffness, resolve inflammation, and improve healing of soft tissues.

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a. Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase. c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has a generalized body response. f. A scar forms during the proliferation phase.

Answer: a. Hemostasis occurs immediately after the initial injury. c. White blood cells move to the wound in the inflammatory phase. e. During the inflammatory phase, the patient has a generalized body response. Rationale: Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking out of plasma and blood components into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b. Draw the shape of the wound and describe how deep it appears in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

Answer: a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. Rationale: To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright red sanguineous drainage indicated fresh bleeding and darker drainage indicated older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f. Serosanguineous drainage can be dark yellow or green depending on the causative organ.

Answer: a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright red sanguineous drainage indicated fresh bleeding and darker drainage indicated older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. Rationale: Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-Red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirt area to the clean area. e. Clean to at least one inch beyond the end of the new dressing if one is being applied. f. Clean to at least three inches beyond the wound if a new dressing is not being applied.

Answer: a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. e. Clean to at least one inch beyond the end of the new dressing if one is being applied. Rationale: The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten a sterile gauze pad or swab with prescribed cleaning agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least one inch beyond the end of the new dressing, and (6) clean to at least two inches beyond the wound margins if a dressing is not being applied.

What observation should the nurse note about a client's open wound if the wound is healing by the third-intention? a. Wound edges are widely separated and brought together with closure material. b. Wound edges are widely separated leading to complex reparative process. c. Wound edges are close to each other but require closure material. d. Wound edges are directly next to each other.

Answer: a. Wound edges are widely separated and brought together with closure material. Rationale: With third-intention healing, the wound edges are widely separated and are later brought together with some type of closure material. First-intention healing, also called healing by primary intention, is a reparative process in which the wound edges are directly next to each other. In second-intention healing, the wound edges are widely separated, leading to a move time-consuming and complex reparative process. However, edges that are near or close to each other do not require closure material.

The nurse is preparing to measure the depth of a client's tunneled wound. Which of the following implements should the nurse use to measure the depth accurately? a. An otic curette. b. A sterile, flexible applicator moistened with saline. c. A sterile tongue blade lubricated with water soluble gel. d. A small plastic ruler.

Answer: b. A sterile, flexible applicator moistened with saline. Rationale: A sterile, flexible applicator is the safest implement to use. The other implements are too large, inflexible, or not sterile.

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure? a. Clean the wound from the bottom to the top, and outside to center. b. Clean the wound from the top to the bottom, and center to outside. c. Once the wound is cleaned, dry the area with an absorbent cloth. d. Use clean technique to clean the wound.

Answer: b. Clean the wound from the top to the bottom, and center to outside. Rationale: 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 in the same manner and apply ointment and dressing.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a. Do not attempt to remove the sutures because they need more time to heal. b. Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. c. Pick the crusts off the sutures with the forceps before removing them. d. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them.

Answer: b. Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. Rationale: 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 sutures.

The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? a. Irrigate the wound. b. Provide gentle cleansing of the wound. c. Débride the wound. d. Change the dressing frequently.

Answer: b. Provide gentle cleansing of the wound. Rationale: Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires débridement (removal) before the wound can heal.

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? a. Stimulating the wound bed to promote the growth of granulation tissue. b. Removing dead or infected tissue to promote wound healing. c. Removing excess drainage and wet tissue to prevent maceration of surrounding skin. d. Removing purulent drainage from the wound bed in order to accurately assess it.

Answer: b. Removing dead or infected tissue to promote wound healing. Rationale: Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicated a high risk for pressure ulcer development for this patient? Select all that apply. a. The patient takes time to think about her responses to the questions. b. The patient's age of 86 years. c. Patient reports inability to control urine. d. A schedule hip arthroplasty. e. Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL). f. Patient reports increased pain in right hip when repositioning in bed or chair.

Answer: b. The patient's age of 86 years. c. Patient reports inability to control urine. d. A schedule hip arthroplasty. f. Patient reports increased pain in right hip when repositioning in bed or chair. Rationale: Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure ulcer development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure ulcer development. Apathy, confusion, and/or altered mental status are risk factors for pressure ulcer development. Dehydration (indicated by and elevated BUN and creatinine) is a risk for pressure ulcer development.

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? a. Gauze b. Transparent c. Hydrocolloid d. Bandage

Answer: b. Transparent Rationale: The nurse should use a transparent dressing to cover the IV insertion site because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage. A hydrocolloid dressing helps keep the wounds moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicated that the patient understand the explanation? a. "I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied."

Answer: c. "I should see less swelling and redness with the cold treatment." Rationale: The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduce blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

While the nurse is preparing the client with a leg wound fro heat therapy, the client asks the nurse how long the warm compress will need to stay on since he wants to get up and walk. What would be the nurse's best response? a. Five minutes each hour b. 1 hour c. 20 to 30 minutes d. Two hours each morning and evening

Answer: c. 20 to 30 minutes Rationale: Heat produces maximum vasodilation in 20 to 30 minutes. If heat is continued beyond that time, tissue congestion and vasoconstriction can occur and this can be detrimental to healing.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a. In children younger than 2 years, the skin is thicker and stronger than in adults. b. A child's skin becomes less resistant to injury and infection as the child grows. c. An infant's skin and mucous membranes are easily injured and at risk for infection. d. An individual's skin changes little over the life span.

Answer: c. An infant's skin and mucous membranes are easily injured and at risk for infection. Rationale: An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a. Enhanced healing due to the presence of sugars and proteins. b. Delayed healing due to dead tissue present in the wound. c. Decreased effectiveness of antibiotics against the bacteria. d. Impaired skin integrity due to over hydration of the cells of the wound. e. Delayed healing due to cells dehydrating and dying. f. Decreased effectiveness of the patient's normal immune process.

Answer: c. Decreased effectiveness of antibiotics against the bacteria. f. Decreased effectiveness of the patient's normal immune process. Rationale: Wound biofilms are the result of wound bacteria growing in clumps, imbedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient. Necrosis (dead tissue) in the wound delays healing. Maceration or over hydration of cells related to bring and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a. Pain b. Impaired Skin Integrity c. Disturbed Body Image d. Disturbed Thought Processes

Answer: c. Disturbed Body Image Rationale: Wounds cause emotional as well as physical stress.

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? a. Jackson-Pratt drain b. Hemovac drain c. Penrose drain d. Wound pouching

Answer: c. Penrose drain Rationale: Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. Jackson-Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery. Wound pouching is used on wounds that have excessive drainage.

A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the perform the following interventions? Arrange from first to last. a. Notify the physician immediately of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile NSS. c. Place the patient in the low Fowler's position.

Answer: c. Place the patient in the low Fowler's position. b. Cover the exposed tissue with sterile towels moistened with sterile NSS. a. Notify the physician immediately of the situation. Rationale: Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position, cover the exposed tissue with sterile towels moistened with sterile NSS, and notify the physician immediately of the situation.

A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less car tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

Answer: c. The therapy provides a moist environment and stimulates blood flow to the wound. Rationale: Negative-pressure wound therapy (or topical negative pressure [TNP]) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound issues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? a. Alginates b. Transparent films c. Hydrogels d. Hydrocolloid dressings

Answer: d. Hydrocolloid dressings Rationale: Hydrocolloids are occlusive or semi-occlusicce dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small, partial-thickness wound with minimal drainage.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a. Using a sterile dressing supply b. Suggesting dietary supplements c. Applying antibiotic ointment d. Performing careful hand hygiene

Answer: d. Performing careful hand hygiene Rationale: Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which of the following modifications is the most appropriate? a. Assure that the packing material is completely saturated when placed in the wound. b. Use less packing material. c. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. d. Reduce the time interval between dressing changes.

Answer: d. Reduce the time interval between dressing changes. Rationale: A hydrocolloid dressing is not indicated.

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition? a. There is an accumulation of fluid in the interstitial tissue. b. The edges of the wound are lightly pulled together. c. There is redness or inflammation of an area as a result of dilation. d. There is an accidental separation of the wound.

Answer: d. There is an accidental separation of the wound. Rationale: With dehiscence, there is an accidental separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together. Edema is an accumulation of fluid in the interstitial tissue. Redness or inflammation of an area as a result of dilation is erythema.

A nurse is developing a plan of care related to prevention of pressure ulcers for residents in a long-term care facility. Which action would be a priority in preventing a patient from developing a pressure ulcer? a. Keeping the head of the bed elevated as often as possible. b. Massaging over bony prominences. c. Repositioning bed-bound patients every 4 hours. d. Using a mild cleansing agent when cleansing the skin.

Answer: d. Using a mild cleansing agent when cleansing the skin. Rationale: To prevent pressure ulcers, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. the nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

A client has developed blisters around the tape that secures the dressing. The nurse should a) Use Montgomery straps b) Apply the dressing with a binder c) Apply skin barrier to protect skin d) Apply tape to the side of the blisters

Apply dressing with a binder

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

Assess the wound for active bleeding. Negative-pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed. NPWT is not considered for the use in the presence of active bleeding. The nurse needs to assess for the use of anticoagulants, not antihypertensives, because these can cause bleeding. Mental status and the presence of claustrophobia are not significant when initiating negative-pressure wound therapy. (less)

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? a. Enzymatic debridement b. Autolytic debridement c. Biosurgical debridement d. Mechanical debridement

Biosurgical debridement

A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development? a) Glascow scale b) Braden scale c) Morse scale d) FLACC scale

Braden scale

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure? a) Once the wound is cleaned, dry the area with an absorbent cloth. b) Clean the wound from the top to the bottom, and center to outside. c) Clean the wound from the bottom to the top, and outside to center. d) Use clean technique to clean the wound.

Clean the wound from the top to the bottom, and center to outside

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care?

Cleanse with a new gauze for each stroke. When cleansing a wound the nurse should use a new gauze or swab on each downward stroke using the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles beginning in the center and working toward the outside. (less)

Which is not considered a skin appendage? 1. Sebaceous gland 2. Hair 3. Connective tissue 4. Eccrine sweat glands

Connective tissue

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Which of the following is the correct order of steps the nurse should perform during this dressing change? 1. Apply a vacuum device to wound 2. Place the drape to cover the wound and an additional 3-5 cm 3. Cut the foam to the shape and measurement of the wound 4. Use sterile gloves 5. Cut a 2-cm hole in the drape 6. Ensure that negative pressure has been achieved

Correct Order Is: 4. 3. 2. 5. 1. 6.

Upon review of a postoperative patient's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a) Laxatives b) Corticosteroids c) Antihypertensive drugs d) Potassium supplements

Corticosteroid

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a) Necrosis b) Desiccation c) Maceration d) Evisceration

Desiccation

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication?

Evisceration

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing? a. Fish b. Green Beans c. Pasta Salad d. Banana

Fish

Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a patient's wound? (Select all that apply.) a) Using clean technique, open the supplies and dressings and place the fine-mesh gauze into the basin, pouring the ordered solution over the mesh to saturate it. b) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. c) Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. d) Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. e) Put on clean gloves and squeeze excess fluid from the gauze dressing before packing it tightly in the wound. f) Apply one dry, sterile gauze pad over the wet gauze, and then place an ABD pad over the gauze pad.

Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. • Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. • Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end.

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?

Impaired tissue integrity

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which of the following actions should the nurse perform in obtaining a wound culture? a) Utilize the culture swab to obtain cultures from multiple sites. b) Stroke the culture swab on surrounding skin first. c) Keep the swab and inside of the culture tube sterile. d) Cleanse the wound after obtaining the wound culture. Keep the swab and inside of the culture tube sterile

Keep the swab and inside of the culture tube sterile

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a) Pick the crusts off the sutures with the forceps before removing them. b) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. d) Do not attempt to remove the sutures because they need more time to heal.

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures

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:

Primary intention. Wounds healing by primary intention form a clean, straight line with little loss of tissue. Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue. Wounds healing by delayed primary intention or tertiary intention are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed. Dehiscence is wound separation, not wound healing. (less)

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the client's chance of skin breakdown? a. Ensure the client is adequately hydrated. b. Reposition the client on a regular basis. c. Massage or stimulate the client's skin surfaces daily. d. Keep the client in a semi-Fowler's or high-Fowler's position.

Reposition the client on a regular basis.

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which of the following types of wound repair would the nurse expect with this wound? a) Secondary intention b) Tertiary intention c) Desiccation d) Primary intention

Secondary Intention

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing describes this? a. Secondary intention b. Tertiary intention c. Maturation d. Primary intention

Secondary Intention

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which of the following types of wound repair would the nurse expect with this wound? a) Tertiary intention b) Desiccation c) Primary intention d) Secondary intention

Secondary intention

A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document?

Serosanguineous

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? a. ischemia b. friction c. shearing force d. necrosis of tissue

Shearing force

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces?

a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down. (less)

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing?

a client who is taking corticosteroid drugs a client with a peripheral vascular disorder a client who is obese an older adult who is confined to bed

The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces? a) A patient who lifts himself up on his elbows b) A patient who lies on wrinkled sheets c) A patient who must remain on his back for long periods of time d) A patient sitting in a chair who slides down

a patient sitting in a chair who slides down

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

a surgical incision with sutured approximated edges

A nurse is caring for a client who has recently undergone hernial surgery. The nurse knows that which of the following are possible causes of complications with regard to surgical wounds? Select all that apply. a) Weak tissue and muscular support due to obesity b) Distension of the abdomen from accumulated intestinal gas c) Insufficient protein and vitamin C intake d) Compromised blood circulation e) Serous fluid accumulation prevents skin tissue approximation

a. b. c.

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 of the following actions by the nurse are appropriate in this situation? Select all that apply. a) Place client in low Fowler's position b) Pack the wound with iodoform gauze c) Use sterile techniques d) Cover wound with a gauze moistened with normal saline e) Reinsert protruding structures and apply a pressure dressing

a. c. d.

A med-surg nurse is assessing wounds of patients. Which wound complications are accurately described below? (Select all that apply.) a) Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site b) Delayed wound healing in patients who are thin and at greater risk for complications owing to a thinner layer of tissue cells c) Dehiscence, which is present when there is a partial or total disruption of wound layers d) A wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5, which is a sign of an impending evisceration e) Evisceration, which occurs when the viscera protrudes through the incisional area f) Symptoms of wound infection, which are usually apparent within 1 to 2 weeks after the injury or surgery

a. c. e.

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? a. Depth b. Tunneling c. Size d. Direction

a. Depth Rationale: When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grass the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler.

You are caring for a patient who has a heavy exudating wound that needs autolytic debridement. Which of the following wound dressings/products is most appropriate to use on the wound? a) Transparent film, such as Tegaderm b) A hydrogel dressing such as Aquasorb c) An antimicrobial dressing, such as SilvaSorb d) An alginate dressing, such as AlgiCell

an alginate dressing, such as AlgiCell (Antimicrobial dressings are appropriate for chronic wounds at risk for infection.)

Which interventions might a nurse be expected to perform when providing competent care for a patient with a draining wound? (Select all that apply.) a) Apply an absorbent dressing material as the first layer of the dressing. b) Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. c) Apply a nonabsorbent material over the first layer of absorbent material. d) Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. e) Change the dressing midway between meals. f) Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary.

b. e. f.

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a) Contact the surgeon for deibridement. b) Using sterile technique, debride the wound. c) Off-load pressure from the heel. d) Place a TED hose on the client's leg.

c) Off-load pressure from the heel

Which of the following actions should the nurse perform when applying negative pressure wound therapy? a. Irrigate the wound thoroughly using normal saline and clean technique. b. Increase the negative pressure setting until drainage is brisk. c. Cut foam to the shape of the wound and place it in the wound. d. Test the seal of the completed dressing by briefly attaching it to the wall suction.

c. Cut foam to the shape of the wound and place it in the wound. Rationale: When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

A physician orders the application of a warm, sterile compress to reduce edema in a client's wound. Which of the following is a recommended step in this procedure? a. Place an aquathermia or heating device directly on the dressing. b. Cover the site with three layers of gauze and with a clean, dry bath towel. c. Keep the dressing in place for the prescribed amount of time or up to 30 minutes. d. Apply pressure to the compress to mold it around the wound site.

c. Keep the dressing in place for the prescribed amount of time or up to 30 minutes. Rationale: After the prescribed time for the treatment (up to 30 minutes), the external heating device should be removed. The compress should be applied by gently and carefully molding it around the wound site. The site should be covered with one layer of gauze and the heating device should be placed over a towel covering the dressing.

Which of the following actions should the nurse perform when applying negative pressure wound therapy? a) Test the seal of the completed dressing by briefly attaching it to wall suction. b) Increase the negative pressure setting until drainage is brisk. c) Irrigate the wound thoroughly using normal saline and clean technique. d) Cut foam to the shape of the wound and place it in the wound

cut foam to the shape of the wound and place it in the wound

A nurse is caring for a client who has a pressure ulcer on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which of the following classifications should the nurse document? a) Unstageable b) Yellow classification (cleanse) c) Red classification (protect) d) Black classification (debride)

d) Black classification (debride)

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? a) Infection of the wound b) Evisceration of the viscera c) Dehiscence of the wound d) Herniation of the wound

dehiscence of the wound

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? a) Stage IV b) Stage I c) Stage II d) Stage III

stage II

A nurse is assessing a pressure ulcer 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 of the following stages should the nurse assign to this client's wound? a) Stage III b) Stage IV c) Stage II d) Stage I

stage III

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? a) Reduces swelling and inflammation b) Maintains a moist environment c) Supports the area around the wound d) Keeps the wound clean

supports the area around the wound

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage? a) On the output sheet b) Under the skin c) In the axilla d) Under the client

under the client

A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn? a. usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown b. may vary from brown or black to cherry red or pearly white; bullae may be present c. superficial, may be pinkish or red with no blistering d. also called a superficial partial-thickness burn, can appear dry and leathery

usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown

A nurse assessing the skin of clients knows that the following are health states that may predispose clients to skin alterations. Select all that apply.

• Obesity • Excessive perspiration • Low BMI