Chapter 32- Skin Integrity and Wound Care

Diffuse dermatitis accompanied by pruritus

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

applying sterile dressings with normal saline over the protruding organs and tissue

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

use pillows to maintain a side-lying position as needed

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

a surgical incision with sutured approximated edges

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

Increases the risk of infection by contaminating the wound

The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care for dressing changes?

Discontinue the therapy and assess the client.

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?

To splint the area when engaging in activity

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

cleanse with a new gauze for each stroke

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

"Very little scar tissue will form."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

foul-smelling drainage that is grayish in color

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection?

a critical care client

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury?

elevating and supporting the stump

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

Stop removing staples and inform the surgeon

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?

subcutaneous tissue

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

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?

A client who has a partial-thickness venous ulcer with moderate drainage

For which client would the application of a hydrocolloid dressing be most appropriate?

Desiccation

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?

corticosteroids

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

Stage II

client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

a transparent film

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 to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site?

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

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

Assess the client's wound and vital signs.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

The status of the client's tetanus immunization

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

removing dead or infected tissue to promote wound healing

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

mechanical debridement

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

Tearing of a structure from its normal position

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion?

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

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Dehiscence of the wound

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?

dehiscence

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

contusion

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

a client sitting in a chair who slides down

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?

applies wrap from proximal to distal direction

The nurse has delegated applying an elastic bandage with clips to the right knee of a 12-year-old client to the unlicensed assistive personnel (UAP). Which action will the nurse determine the UAP needs additional training?

Apply a skin protectant to the skin around the incision.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

serosanguineous

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

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 is this?

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

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?

An infant's skin and mucous membranes are easily injured and at risk for infection.

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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?

stage IV

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?

preventing the client from sliding in bed

The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force?

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

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

Fish

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?

Fingers with quick capillary refill Warm hand No finger numbness or tingling

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

stage II

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

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?

serosanguineous

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?

evisceration

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?

a sterile, flexible applicator moistened with saline

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?

Apply saline solution-moistened gauze over the protruding area.

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