Chapter 33 Skin Integrity

Which instruction should the nurse give to a client to ensure that a nasal medication is deposited within the nose rather than into the throat?

"Aim the tip of the container toward the nasal passage."

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

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?

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

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?

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

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

"Very little scar tissue will form."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

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

The nurse is preparing to insert an intravenous needle in a 1-year-old child for a one-time administration of fluids due to dehydration. Which needle would the nurse likely select?

*A 23-gauge winged infusion set. -Winged infusion or small vein needles may be used for short-term or one-time infusion therapies or may be used with infants and small children. These are short, beveled needles with plastic flaps or wings.

The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply.

-A nurse places a transparent dressing over a central venous access device insertion site. -A nurse uses aseptic techniques when changing a dressing. -A nurse places a drainage dressing around a drain insertion site.

A client with a complex cardiac history has been prescribed digoxin 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?

0.5

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?

1500

A nurse is administering a piggyback infusion to a client with partial-thickness or second-degree burns. Which describes the most important feature of a piggyback infusion?

A parenteral drug is given in tandem with an IV solution.

The nurse is caring for a client who has problems coordinating his breathing with the inhaler use. Therefore, the client is unable to receive the full dose. Which would help maximize drug absorption in this client?

A spacer would help maximize the absorption of the drug in a client who is having problems coordinating his breathing with the inhaler use. A spacer provides a reservoir for the aerosol medication. As the client takes additional breaths, he continues to inhale the medication held in the reservoir. This tends to maximize the drug's absorption because it prevents drug loss

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

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

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

Apply saline solution-moistened gauze over the protruding area.

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

Assess the client's wound and vital signs.

A nurse is using an IV port when administering medication to a client. Which IV administration has the greatest potential to cause life-threatening changes?

Bolus administration

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

Braden Scale

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.

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?

Client receiving chemotherapy The nurse should determine that the client receiving chemotherapy is the client at greatest risk for VRE infection due to having a compromised immune system from the chemotherapy. Other risk factors for VRE include recent abdominal or chest surgery, presence of urinary or central IV catheter, prolonged antibiotic use (especially with vancomycin), and lengthy hospital stays (especially in an ICU).

Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply.

During some care activities for an individual client, nurses may need to change gloves more than once. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?

Exogenous healthcare-associated

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?

Increases the risk of infection by contaminating the wound

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?

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

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?

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

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next?

Perform hand hygiene

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action?

Place the date on the vial and retain for future use.

The nurse is administering morphine 5 mg oral solution, which is located in a locked drawer in the medication room. The medication is provided in a unit-dose container that is labeled 10 mg/5 ml. What action(s) are required for the nurse to perform?

Provide written documentation for the removal of the medication dose. Obtain another nurse to witness the waste of the unused medication. Count the number of the morphine unit-dose containers prior to removal. Document each shift by two nurses that an opioid count was performed.

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

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

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?

Serosanguineous

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?

Stage IV

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

A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection?

Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis.

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?

Tearing of a structure from its normal position

The nurse is creating a professional development presentation about medication orders. Which teaching will the nurse include? Select all that apply.

The health care providers must sign all orders. Be extra cautious with look-alike and sound-alike drugs.

Which parts of the syringe and needle must be kept sterile when preparing and administering an injection? Select all that apply.

The needle hub The needle Inside the barrel

Which nursing strategy should the nurse employ to assist a child who has difficulty coordinating inspiration with the use of a handheld inhaler?

The nurse should use a nebulizer to administer the medication.

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

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

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?

The status of the client's tetanus immunization

A nurse needs to administer a prescribed injection to an older adult client with impaired mobility. Which intramuscular site is preferred for administering an injection to older adult clients?

Ventrogluteal

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

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 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 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 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 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?

a critical care client

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

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

an obese woman with a history of type 1 diabetes

Which is not considered a skin appendage?

connective tissue

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

corticosteroids

The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe?

decreased irritation and pain in subcutaneous tissue

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?

desiccation

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing

fish

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?

foul-smelling drainage that is grayish in color

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

hydrocolloid

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

intradermal

Which parenteral route of administration has the longest absorption time?

intradermal

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

keeping sterile field above waist level

The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?

placing the secondary infusion higher than the primary solution

A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the:

prodromal period

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

remove gloves, remove gown, wash hands

The client, after undergoing an appendectomy for a ruptured appendix, has an open drain left in the wound. The health care provider prescribes removal of 2 in (5 cm) of drain every day. Which action will the nurse take?

reposition the safety pin or clip on the drain

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?

secondary intention

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?

subcutaneous tissue

The nurse observes a member of the care team removing a gown after assisting a client with hygiene, as seen in image above. What is the nurse's most appropriate action?

teach the colleague to let the gown fall away rather than pulling on the sleeves

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?

transparent film

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?

use pillows to maintain a side-lying position as needed

A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client?

vastus lateralis site