Chapter 32: Skin Integrity and Wound Care

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? "Douching is recommended so that you are clean for the examination." "Do not douche for 24-48 hours before the procedure." "The Pap procedure includes application of a douche." "Plan to begin douching routinely immediately after your procedure."

"Do not douche 24-48 hours before the procedure." Explanation: Clients should be informed to refrain from douching 24-48 hours prior to a Pap test, as this can wash away diagnostic cells. The healthcare provider is unlikely to recommend routine douching; this procedure is usually used to assist with treatment of an infection. The Pap procedure involves obtaining cell samples; it does not include application of a douche.

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? "That is necrotic tissue, which must be removed to promote healing." "That is called undermining, a type of tissue erosion." "That is old clotted blood underneath the wound" "This is normal tissue."

"That is necrotic tissue, which must be removed to promote healing." Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate? "The condition is hard to cure." "You will likely experience periods of increased skin outbreaks and periods of remissions." "Your personal health habits will dictate how well you handle this condition." "You will have this disease for life."

"You will likely experience periods of increased skin outbreaks and periods of remissions." Psoriasis is a chronic condition. It may be managed with lifestyle changes and medications. There is no permanent cure. Periods of remission are followed by exacerbations, which can be triggered by stress, infection, or environmental factors.

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

an obese woman with a history of type 1 diabetes -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.

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: evisceration. dehiscence. herniation. infection.

dehiscence.Explanation:Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? serosanguineous serous purulent sanguineous

serosanguineous This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

The health care provider has ordered a cold ice bag to be applied to the wrist of a client with a sprain. The nurse will ensure that the cold application is at what temperature before application? 10°-18.3° C (50°-65° F) 18.3°-26.6° C (65°-80° F) Below 10° C (below 50° F) 26.6°-33.8° C (80°-93° F)

Cold applications should be between 10° and 18.3° C (50°-65° F). An application of 26.6° to 33.8° C (80°-93° F) is tepid; 18.3°- 26.6° C (65°-80° F) is cool; below 10° C (below 50° F) is very cold.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? Document the pain and vital signs. Assess the client's wound and vital signs. Administer the prescribed analgesic. Notify the health care provider of the pain.

First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

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? Banana Pasta salad Green beans Fish

Fish To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

A nurse is caring for an adult who had Mohs surgery on the nose. The client asks, "Is there anything I can do to prevent getting skin cancer again?" How should the nurse respond? "Absolutely, skin cancer can be prevented by limiting exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing." "There are preventative measures you should take to limit exposure to UVA and UVB rays, such as only going outside when there is cloud cover; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." "There are preventative measures you should take to limit exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." "I am so sorry, there are preventative measures such as limiting your exposure to UVA and UVB rays; however, since you have had skin cancer I am uncertain this would help you. You should continue to inspect you skin for suspicious findings and see your dermatologist as recommended."

"There are preventative measures you should take to limit exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." The client should be educated about the importance of preventing skin cancer by limiting exposure to UVA and UVB rays. The use of clothing, such as long-sleeve shirts, wide-brimmed hats, and sunglasses, in addition to the use of sunscreen should be encouraged. Preventative measures are not an absolute guarantee that a client will not get skin cancer, and someone who has been diagnosed previously with skin cancer is at greater risk. UVA and UVB rays can penetrate clouds, only going out on cloudy days will not protect the skin from exposure.

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

A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

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. Use clean technique to clean the wound. Clean the wound in a circular pattern, beginning on the perimeter of 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 center to outside. Explanation: 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.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? Document the findings in the client's medical record. Discontinue the therapy and assess the client. Gently rub and massage the area to warm it up. Notify the health care provider of the findings.

Discontinue the therapy and assess the client. The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.

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

EviscerationExplanation: Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

A skin infection caused by beta-hemolytic streptococci common in children is: acne vulgaris. scabies. herpes. impetigo.

Impetigo, which usually is caused by beta-hemolytic streptococci, is the most common bacterial skin infection.

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 heart must be able to pump adequately. The volume of circulating blood must be sufficient.

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 the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Stop removing staples and inform the surgeon Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision. Apply adhesive wound closure strips after each staple is removed.

Stop removing staples and inform the surgeonExplanation:If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.

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

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client's neck. The nurse would not cover the heating pad with a heavy blanket.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To remain in bed for the next 4 hours To turn the head away from the area whenever coughing To ambulate using a cane or walker To splint the area when engaging in activity

To splint the area when engaging in activity To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

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? transparent hydrocolloid tape with eyelets gauze

gauze Gauze dressings absorb blood or drainage. Strips of tape with eyelets are used to secure a gauze dressing that needs frequent changing; they are not necessary for this type of wound. Transparent dressings are used to protect intravenous insertion sites. Hydrocolloid dressings are used to keep a wound moist.

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 removing excess drainage and wet tissue to prevent maceration of surrounding skin removing purulent drainage from the wound bed in order to accurately assess it stimulating the wound bed to promote the growth of granulation tissue

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.

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? elevate the head of the bed 90 degrees provide incontinent care every 4 hours as needed place a foot board on the bed use pillows to maintain a side-lying position as needed

use pillows to maintain a side-lying position as needed Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? As a stage III pressure injury As a stage II pressure injury As a stage I pressure injury As a stage IV pressure injury

As a stage I pressure injury Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV.

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 the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Evisceration Desiccation Maceration Necrosis

Desiccation is localized wound dehydration. Maceration is localized wound overhydration 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.

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? Tetanus, being able to walk, and scarring Scarring, sutures, and wound care Prevention of recurring infection, ability to work, and wound care Tetanus, infection, wound care, and pain control

Tetanus, infection, wound care, and pain control Chances are the client knows that stepping on a nail could lead to a serious complication or illness, even if the client cannot remember or does not know about tetanus or infections. How to care for the wound is usually something clients will want to know before being discharged. The client in this scenario is reporting pain, so pain control will be one of the concerns. It is unlikely that the client will be worried about scarring on the bottom of the foot or sutures due to it being a puncture. The client is still walking, although in pain and with a limp, it would be unlikely the client would be concerned about being able to walk. More than likely, the client has already figured out the injury may not have occurred or would not be as bad had he or she been wearing shoes, so the nurse would not anticipate the need for preventative education.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To splint the area when engaging in activity To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing

To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

A client with a history of pressure injuries is discussing nutrition with the nurse. The client correctly indicates plans to include which vitamin in the diet to promote wound healing? Select all that apply. Vitamin B6 (pyridoxine) Vitamin D Vitamin B7 (biotin) Vitamin B9 (folic acid) Vitamin B3 (niacin)

Vitamin B6 (pyridoxine) Vitamin B3 (niacin) Adequate intake of vitamins A, B6, C, K, niacin, and riboflavin is important to prevent abnormal skin changes.

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." "This procedure can be safely preformed using clean technique if care is taken not to touch the wound." "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin."

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

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? Infection of the wound Herniation of the wound Dehiscence of the wound Evisceration of the viscera

Dehiscence of the wound Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. Rotate the swab several times over the wound surface to obtain an adequate specimen.

The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound applying sterile dressings with normal saline over the protruding organs and tissue

The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

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 action should the nurse perform in obtaining a wound culture? Utilize the culture swab to obtain cultures from multiple sites. Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

The swab and the inside of the culture tube should be kept sterile prior to the procedure. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

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 sitting in a chair who slides down a client who lies on wrinkled sheets a client who lifts himself up on the elbows a client who must remain on the back for long periods of time

a client sitting in a chair who slides down Explanation: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.

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 an otic curette a sterile tongue blade lubricated with water soluble gel a small plastic ruler

a sterile, flexible applicator moistened with saline A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.

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 a gauze dressing precut halfway to fit around the IV line a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics

a transparent film Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms. Gauze dressings--precut, with an adherent coating, premedicated with antibiotics--do not allow the nurse to visualize the site without partially or completely removing the dressing.

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. a client who is taking corticosteroid drugs a 10-year-old client with a surgical incision a client who eats a diet high in vitamins A and C an older adult who is confined to bed a client who is obese a client with a peripheral vascular disorder

an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drugs There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure injury formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client. A client who eats a diet high in vitamins A and C would not be at risk for delayed wound healing. A 10-year old client with a surgical incision would not be at risk for delayed wound healing.

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. secondary intention. tertiary intention. dehiscence.

primary intention.Explanation: 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.

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely: first degree or superficial fourth degree or fat layer second degree or partial thickness third degree or full thickness

second degree or partial thickness Partial-thickness burns may be superficial or moderate to deep. A superficial partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good example. Moderate to deep partial-thickness burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present. The full-thickness burn appears dry and leathery.

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 is this? tertiary intention maturation secondary intention primary intention

secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

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? stage I stage IV stage III stage II

stage III Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss, such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?" "Do you experience incontinence?"

"Do you experience incontinence?" The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments? Reassess the coccyx area for fading of the redness in 60 to 90 minutes. Document the presence of a pressure injury and develop a care plan. Immediately report to the physician that the client has a pressure injury. Implement nursing interventions for altered skin integrity.

Reassess the coccyx area for fading of the redness in 60 to 90 minutes.Explanation:Blanching of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer. To verify it is reactive hyperemia, the nurse reassesses the area in 60 to 90 minutes. The redness should fade within this time.

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." "This is a complex reparative process." "Very little scar tissue will form." "The surgeon will leave your wound open intentionally for a period of time."

Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

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? bandage transparent gauze hydrocolloid

transparent 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 wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Use an aquathermia pad during the treatment to create heat and circulate the water. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue

Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Warm soaks and dressing changes can be painful for clients with abscesses. Often, nurses will premedicate with pain medications, often opioids, 20 to 30 minutes prior to make the treatments more comfortable for clients. Increasing client comfort can increase effectiveness by allowing the nurse time to adequately perform the treatment, assess the wound, and apply the new dressing. Aquathermia pads are used to promote wound healing, but they are not used simultaneously with water therapies. Dangling the legs and ambulating will not increase comfort.

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

Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of 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? Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Do not attempt to remove the sutures because the wound needs more time to heal. 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.

Moisten sterile gauze with sterile saline to gently 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 the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

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? hydrocolloid dressing hydrogel sheet transparent film 2 × 2 in (5 × 5 cm) gauze

To secure an IV catheter, the nurse uses a transparent film. The transparency film allows visualization of the IV site, is self-adhesive, and protects against contamination. The 2 × 2 in (5 × 5 cm) gauze dressing does not allow visualization of the IV site and does not protect against moisture. The hydrocolloid dressing does not allow visualization of the IV site and is best used in wounds with light to moderate drainage. Hydrogel sheets are not an appropriate dressing for an IV site. They do not allow visualization of the IV site and are best used in partial- and full-thickness wounds, burns, dry wounds, wounds with minimal exudate, necrotic wounds, and infected wounds.