Chapter 33: Skin integrity and Wound Care , Foundations Chapter 33: Skin Integrity and Wound Care, Foundations Chapter 32: Hygiene, PrepU Chapter 25: Aspesis and Infection Control, Chapter 25 "Asepsis and infection control" TB/coarse point questions

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

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

"Do you experience incontinence?"

The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. - Hang the bag of tepid to warm water at the client's chest height on an IV pole - Ensure that the call bell is within reach - Insert tubing into the infusion port of the sitz bath - Fill the bowl of the sitz bath about halfway full with tepid to warm water - Have the client soak for about 50 to 60 minutes - Slowly unclamp the tubing and allow the sitz bath to fill

- Ensure that the call bell is within reach - Insert tubing into the infusion port of the sitz bath - Fill the bowl of the sitz bath about halfway full with tepid to warm water - Slowly unclamp the tubing and allow the sitz bath to fill

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety? - The nurse uses droplet precautions when providing care for the client. - The nurse places the client in a private room with open door. - The nurse keeps visitors 3 feet away from the infected person. - The nurse places the client in a private room with monitored negative air pressure.

- The nurse places the client in a private room with monitored negative air pressure.

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure? - The nurse uses soap and cold water to wash hands. -The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands. - The nurse rinses thoroughly with water flowing away from the fingertips. - The nurse washes at least 1 in (2.5 cm) above the area of contamination if present.

- The nurse washes at least 1 in (2.5 cm) above the area of contamination if present.

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. - Warm hand - Decreased radial pulse - Fingers with quick capillary refill - Cyanosis - No finger numbness or tingling

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

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

- client receiving chemotherapy

means of transmittion

- direct contact (touch) - indirect contact a. vector: living creature that transmit an infectious agent b. formite: inanimate object

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? - handwashing before leaving the client's room - make contact between two contaminated surfaces - make contact between two clean surfaces - remove the garments that are most contaminated

- handwashing before leaving the client's room

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? Client with a surgical wound OR Client with a urinary catheter

Client with a urinary catheter

A nurse provides care for an adolescent who is diagnosed with mononucleosis. Which crucial information does the nurse include in client education about the condition? Select all that apply. - Cover coughs or sneezes to reduce the risk of spreading infection. - Mononucleosis is called the "kissing disease" so refrain from kissing. - It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact. - Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. - The Epstein-Barr virus (EBV) causes mononucleosis.

Cover coughs or sneezes to reduce the risk of spreading infection. - Mononucleosis is called the "kissing disease" so refrain from kissing. - It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact. - Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. - The Epstein-Barr virus (EBV) causes mononucleosis.

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action? - Change the sterile field, but reuse the sterile equipment. - Proceed with the procedure since it was only touched by the client. - Call for help and ask for new supplies. - Discard the sterile field and the supplies and start over.

Discard the sterile field and the supplies and start over.

Droplet vs airborne transmission

Droplet: Cough or sneeze (greater than 5 mcm) AIrborn: Remains in air (less than 5 mcm)

stages of infection

Incubation period Prodromal stage (early signs and symptoms that are vague and nonspecific; often unaware of being contagious) Full stage of illness decline: # of pathogens decline. signs and symptoms begin to fade Convalescent period: recovery

A nurse has put on personal protective equipment (PPE) to perform the dressing change of a client's surgical wound. While the nurse is cleansing the incision, the client begins bleeding and blood hits the nurse's wrist, running down under the cuff of her glove. What is the nurse's best action? - Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol. - Remove the contaminated gloves and apply a clean pair of gloves. - Perform thorough hand hygiene immediately after completing the dressing change. - Rinse the infected hand with hydrogen peroxide after applying a sterile bandage to the client's wound.

Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol.

Type of MDROs

MRSA: methicillin-resistant staphylococcus aureaus VRE: vancomycin-resistant enterococcus C.Diff: clostridium difficile colitis Other: MDR-TB, Penicillin-resistant strep pneumonia, E.coli Antibiotic Resistant Superbug

organism's potential to produce disease

Number of organisms (the more the better) Virulence (ability to produce disease0 Competence of person's immune system Length/intimacy of contact between person and organism (colonization=long contact)

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? - Ensure that hard surfaces in the room are disinfected at least once per day. - Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. - Place client in a private room that has monitored negative air pressure. - Use a private room with the door closed at all times

Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.

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? a) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." b) "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." c) "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." d) "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider."

a) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the 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? a) "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." b) "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)." c) "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." d) "This procedure can be safely preformed using clean technique if care is taken not to touch the wound."

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

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

a) A client sitting in a chair who slides down

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? a) A transparent film b) A gauze dressing premedicated with antibiotics c) A dressing with a nonadherent coating d) A gauze dressing precut halfway to fit around the IV line

a) A transparent film

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

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

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? a) Applying sterile dressings with normal saline over the protruding organs and tissue b) Monitoring for pallor and mottled appearance of the wound c) Assessing for impaired blood flow to the area of evisceration d) Contacting the surgeon

a) Applying sterile dressings with normal saline over the protruding organs and 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? a) Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures b) Carefully pick the crusts off the sutures with the forceps before removing them c) Do not attempt to remove the sutures because the wound needs more time to heal d) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them

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

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) Rotate the swab several times over the wound surface to obtain an adequate specimen b) Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen c) Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain d) Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station

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

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) Use pillows to maintain a side-lying position as needed b) Place a foot board on the bed c) Provide incontinent care every 4 hours as needed d) Elevate the head of the bed 90 degrees

a) Use pillows to maintain a side-lying position as needed

When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply. a. Comparing bilateral parts for symmetry b. Proceeding in a toe-to-head, systematic manner c. Using standard terminology to communicate and document findings d. Avoiding using data from the nursing history to direct the assessment e. Documenting only skin abnormalities on the health record f. When risk factors are identified, following up with a related skin assessment

a, b, c, f Rationale: During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and preform the appropriate skin assessment when risk factors are identifies. The nurse should proceed in a heat-to-toe systemic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.

A nursing student asks an experienced nurse why they provide massage for their patients. Which of these would be reflected in the nurse's response? a. To help with pain management b. To provide comfort c. To communicate to patients through touch d. To energize patients, especially those with dementia e. To facilitate healing after back or spinal surgery f. To help increase circulation

a, b, c, f Rationale: The benefits of massage include general relaxation and increased circulation, pain relief, sleep promotion, and increased patient comfort and well-being. Massage also provides an opportunity for the nurse to communicate and connect with the patient through touch. Back massage is contraindicated if the patient has had back surgery or has fractured ribs.

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential to good patient outcomes, especially for those receiving mechanical ventilation. What are positive outcomes expected from this care? Select all that apply. a. Promoting that patient's sense of well-being b. Preventing deterioration of the oral cavity c. Contributing to decreased incidence of aspiration pneumonia d. Eliminating the need for flossing e. Decreasing oropharyngeal secretions f. Compensating for an inadequate diet

a, b, c. Rationale: Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene and use of chlorhexidine gluconate (CHG) in critical care areas, can limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of ventilator-associated pneumonia, aspiration pneumonia, and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

A patient is admitted with nonhealing surgical wound. Which nursing interventions will the nurse use to promote wound healing? Select all that apply. a. Applying sterile dressing supplies b. Discussing zinc supplementation with the health care provider c. Maintaining bedrest d. Performing careful hand hygiene e. Teaching the patient to increase protein in the diet f. Suggesting the patient consume vitamin C-containing foods.

a, b, d, e, f. Rationale: Careful hand washing (medical asepsis) is the most important. The nurse will use sterile dressings and supplies and promote intake of vitamins, zinc, and protein. Depending on the site of the wound and the condition of the patient, bedrest may be indicated.

The nurse is cleaning an open abdominal wound that has edges that are not approximated. 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 form the dirty area to the clean area. e. Clean to at least 1 inch beyond the end of the new dressing if one is being applied. f. Clean to at least 3 inches beyond the wound if a new dressing is not being applied.

a, b, e. Rationale: The correct procedure for cleaning an open wound with edges that are not approximated is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing 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 1 inch beyond the end of the new dressing, and (6) clean to at least 2 inches beyond the wound margins if a dressing is not being applied.

A nurse on a surgical unit is working with a nursing student and discussing various phases of wound healing for postoperative patients. 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 generalized body response. f. A scar forms during the proliferation phase.

a, c, e. Rationale: Hemostasis occurs immediately after the initial injury, and exudate occurs in this phase as plasma and blood components leak out into the injured area. White blood cells, predominately 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 teaching a nursing student how to preform perineal care for patients. What actions are appropriate when preforming this procedure? Select all that apply. a. For male and female patients, wash the groin area with a small amount of soap and water and rinse. b. For a female patient, spread the labia and move the washcloth form the anal area toward the pubic area. c. For male and female patients, always proceed from the most contaminated area to the least contaminated area. d. For male and female patient, use a clean portion of the washcloth for each stroke. e. For male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. f. In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis.

a, d, e Rationale: Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth form the pubic area toward the anal area. In an uncircumcised male patient (teenager or older), retract the foreskin (prepuce) while washing the penis and return it to its original position when finished.

A nurse is caring for an adolescence with severe acne. Which recommendations would be the most appropriate to include in the teaching plan for this patient? Select all that apply. a. Wash the skin twice a day with a mild cleanser and warm water. b. Use cosmetics liberally to cover blackheads. c. Apply emollients on the area. d. Squeeze blackheads as they appear. e. Keep hair off the face and wash hair daily. f. Avoid tanning booth exposure and use sunscreen.

a, e, f Rationale: Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face. Exposure to UV light should be avoided, especially when using acne treatments. Liberal use of cosmetics and emollients can clog the pores, worsening acne. Squeezing blackheads is discouraged because it may lead to infection.

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 patient's nursing care plan? a. Document the findings and continue to monitor the patient. b. Administer antipyretics, as prescribed. 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 prescription.

a. Rationale: The 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 site of the injury (surgery, in this case). The patient also has a generalized body response, including mildly elevated temperature, leukocytosis, and generalized malaise.

A nurse caring for a patient with stage 3 pressure wound with tunneling. How will the nurse best assess the tunneled area? 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. Photograph the wound per policy and describe the estimated depth in centimeters. c. Gently insert a sterile applicator into the wound per policy 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.

a. Rationale: To measure the depth of a wound, the nurse should preform hand hygiene and apply 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.

The nurse is caring for a patient 1 day postoperative abdominal surgery. The nurse identifies the patient is at risk for wound dehiscence. What patient risk factor is consistent with development of this problem? a. Cigar smoker b. Wound drainage 120 mL over 24 hours c. Height, 5'6" and weight 240 lb d. WBC count 9,500 c/mm3

a. Rationale: Wound dehiscence is the partial or total separation of wound layers as a result of excessive stress on unhealed wounds. Patients at a greater risk include obese or malnourished individuals, tobacco smokers; and those taking anticoagulants, who have infected wounds, or who experience excessive coughing, vomiting, or straining. An increase in the flow of (serosanguineous) fluid from the wound between postoperative days 4 and 5 may be a sign of impending dehiscence. The patient may say that "something has suddenly given way."

disease carriers - reservoir

asymptomatic but can transmit disease

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

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

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

b) A surgical incision with sutured approximated edges

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? a) Banana b) Fish c) Green beans d) Pasta salad

b) 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? a) Small amount of drainage that appears to be mostly fresh blood b) Foul-smelling drainage that is grayish in color c) Copious drainage that is blood-tinged d) Large amounts of drainage that is clear and watery and has no smell

b) Foul-smelling drainage that is grayish in color

On inspection, the nurse observes that a neonate has sebaceous retention cysts. The nurse will document the presence of which of the following? a) Prickly heat b) Milia c) Lanugo d) Acne vulgaris

b) Milia

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

b) Removing dead or infected tissue to promote wound healing

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? a) Staging the wound for assessment b) The status of the client's tetanus immunization c) If there is contamination of dirt and debris d) The event leading up to the trauma

b) The status of the client's tetanus immunization

A nurse is developing a care plan for an older adult patient who is recovering from a hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for this patient to develop area(s) of pressure injury? Select all that apply. a. The patient takes time to think about responses to questions. b. The patient is an older adult with a poor appetite. c. The patient reports inability to control their urine d. The patient's albumin level is <3.2 mf/dL (normal, 3.4 to 5.4 g/dL). e. Lab findings include BUN 12 (older adult, normal 8 to 23 mg/dL). f. The patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f. Rationale: Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury 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. A low albumin level signals a risk for poor wound healing related to malnutrition. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development; however, taking time to formulate responses is consistent with normal aging. The patient's BUN and creatine are within normal range; however, dehydration (indicated by an elevated BUN and creatine) is a risk for pressure injury development.

A charge nurse in a skilled nursing facility is working to reduce patients' foot and nail problems. The charge nurse reminds the nurses and APs to closely observe which of these patients at higher risk? Select all that apply. a. Patient taking antibiotics for chronic bronchitis b. Patient with type 2 diabetes c. Patient who has obesity d. Patient who frequently bites their nails e. Patient with prostate cancer f. Patient who frequently washes their hands

b, c, d, f. Rationale: Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, hx of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Antibiotic use and prostate cancer do not predispose to foot or nail problems.

A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? Select all that apply. a. Bathing the feet thoroughly in a mild soap and tepid water solution b. Soaking the resident's feet in warm water and bath oil c. Drying the feet and area between the toes thoroughly d. Applying an alcohol rub for odor and dryness to the feet e. Applying an antifungal foot powder f. Cutting the toenails at the lateral corners when trimming the nail

b, d, f Rationale: The nurse corrects the AP for soaking the feet or using alcohol and reminds them to use moisturizer if the feet are dry. Digging into or cutting the toenails at the lateral corners when trimming the nails requires correction; toenails should be trimmed straight across. Guidelines for foot care include bathing the feet thoroughly in a mild soap and tepid water solution; drying the feel thoroughly, including the area between the toes; and applying an antifungal foot powder when requested.

After an initial skin assessment, the nurse documents the presence pressure area that is reddened and has a 1-cm blister. How will the nurse document the wound stage? a. Stage 1 dark maroon wound, skin intact. b. Stage 2 with 1-cm blister noted c. Stage 3 wound bas with red granulation tissue d. Stage 4 blanchable reddened area, 2 cm

b. Rationale: A stage 2 pressure injury 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. Dark maroon or purple wounds with intact skin represent deep tissue injury. Red granulation tissue is present in stage 3 or 4 pressure injuries that are healing. A blanchable, red area is a stage 1 pressure injury.

A nurse assisting with a bed bath observes the older adult has dry skin, which the patient states is "itchy," which intervention is appropriate? a. Bathe the patient more frequently. b. Use an emollient on the dry skin. c. Explain that this is expected as people age. d. Limit the patient's fluid intake

b. Rationale: An emollient soothes dry skin, whereas frequent bathing increases dryness. Telling the patient this is normal with aging and does not help resolve the issue. Limiting fluid intake can promote dehydration and exacerbate dry skin.

An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct? a. When providing perineal care, washing the area from front to back b. Insisting the older adult must take a bath or shower each day c. Telling the patient to avoid soaking feet, helps the patient dry between the toes d. Covering areas not being bathed with a bath blanket

b. Rationale: Older adults tend to develop dry skin; bathing frequency will change accordingly. Soaking adult's feet is not recommended. It is appropriate to keep a patient warm with bath blankets and provide perineal care washing from front to back.

A nurse notes a pressure wound base is red. Using the RYB system for documentation, what intervention is indicated? a. Irrigating the wound and applying an absorbent dressing b. Gently cleansing the wound and applying a moist dressing c. Discussing consultation for surgical debridement with the provider d. Performing frequent dressing changes to keep the wound and dressing dry

b. 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 dressing changes only when necessary (or based on product manufacturer's recommendations). To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigation. The eschar found in black wounds require debridement (removal) before the wound can heal.

A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristics of the wound drainage? Graphic Record: - T 99.9 P 100 RR 20 BP 138/88 - Nursing note: Patient postoperative day 2. Dry sterile dressing changed on abdominal incision. Incision edges are well approximated with a slight 1/2 cm opening at inferior edge; incisional edges reddened. Hemovac draining sanguineous material, 60 mL for the shift. Patient reports moderate pain, relieved by oxycodone X1. a. Sanguineous 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. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria. d. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor.

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

A nurse is caring for a 25-year old patient who is unresponsive following a head injury. The patient has several piercings in the ears and nose that appear crusted and slightly inflamed. What is the most appropriate action to care for this patient's piercings? a. Avoiding removing or washing the piercings until the patient is responsive b. Rinsing the sites with warm water and remove crusts with a cotton swab c. Washing the sites with alcohol and apply an antibiotic ointment d. Removing the jewelry and allow the sites to heal over

b. Rationale: When providing care for piercings, the nurse preforms hand hygiene, applies gloves, then cleanses the site of all crusts and debris by rinsing the site with warm water and removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser, per policy, to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and preform hand hygiene. The should not use alcohol, peroxide, or ointments at the site and should avoid removing piercings unless it is absolutely necessary (e.g., when a MRI is ordered.)

A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient's personal hygiene? a. When the patient had their most recent bath b. The patient's usual hygiene practices and preferences c. Where the bathing fits in the nurse's schedule d. The time that is convenient for the AP

b. Rationale: The patient's preferences, practices, and rituals should always be taken into consideration, unless their is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.

The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions? recognize that this type of infection requires droplet precautions be sure that there are gloves of various sizes and gowns for use

be sure that there are gloves of various sizes and gowns for use C Diff is contact precaution

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

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

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? a) "The margins of your wound are not in direct contact." b) "The surgeon will leave your wound open intentionally for a period of time." c) "Very little scar tissue will form." d) "This is a complex reparative process."

c) "Very little scar tissue will form."

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

c) An obese woman with a history of type 1 diabetes

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? a) Inform the client that this is an expected occurrence and not to worry b) Allow the wound and intestinal contents to remain open to air c) Apply saline solution-moistened gauze over the protruding area d) Pack the wound with gauze pads and a dry sterile dressing

c) 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? a) Administer the prescribed analgesic b) Document the pain and vital signs c) Assess the client's wound and vital signs d) Notify the health care provider of the pain

c) Assess the client's wound and vital signs

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? a) Clean the wound in a circular pattern, beginning on the perimeter of the wound b) Once the wound is cleaned, gently dry the wound bed with an absorbent cloth c) Clean the wound from the top to the bottom and from the center to outside d) Use clean technique to clean the wound

c) Clean the wound from the top to the bottom and from the 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? a) Infection of the wound b) Evisceration of the viscera c) Dehiscence of the wound d) Herniation of the wound

c) Dehiscence of 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? a) Stroke the culture swab on surrounding skin first b) Utilize the culture swab to obtain cultures from multiple sites c) Keep the swab and the inside of the culture tube sterile prior to collecting the culture d) Cleanse the wound after obtaining the wound culture

c) 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 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 modification is most appropriate? a) Use less packing material b) Assure that the packing material is completely saturated when placed in the wound c) Reduce the time interval between dressing changes d) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead

c) Reduce the time interval between dressing changes

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

c) To splint the area when engaging in activity

A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, "something is falling out of my incision!" The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be preformed, arrange from first to last. a. Notify the health care provider of the situation. b. Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. c. Place the patient in the low Fowler position. d. Document the findings and outcome of interventions. e. Maintain NPO status for return to the OR for repair.

c, b, a, e, d. Rationale: The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). The patient is kept NPO, as prompt surgical repair will be needed. After the patient has received attention, the nurse documents all assessments and interventions in a timely manner

The nurse preceptor is supervising a new graduate nurse as they assess a patient with a pressure injury. The graduate nurse documents the presence of biofilm in the wound. The preceptor recognizes the graduate nurse understands this concept when the graduate makes which of these statements? Select all that apply. a. Enhanced healing occurs due to dead tissue present in the wound. b. Delayed healing develops due to dead tissue present in the wound. c. Antibiotics against the bacteria become less effective. d. Skin loses its integrity due to overhydration of the cells of the wound. e. Delayed healing due to cells dehydrating and dying occurs. f. Decreased effectiveness of the patient's normal immune process results.

c, f. Rationale: Wound biofilms are the result of wound bacteria growing in clumps, embedded 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 overhydration of cells related to urinary 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 nurse is providing education to a patient and their family regarding the use of negative pressure wound therapy (NPWT). The nurse documents that the teaching has been effective when the patient and family make which statement? a. "This therapy is used to collect excess blood loss and prevent formation of scab." b. "The suction created will prevent infection and promote wound healing with less scar tissue." c. "Suction stimulates blood flow to the wound, removes excess fluid, and promotes a moist environment for healing." d. "This treatment irrigates the wound, and keeps it free from debris wound exudate."

c. Rationale: Negative pressure wound therapy (NPWT) 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 tissues, 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.

A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? a. Adding bath oil to the water to prevent dry skin b. Allowing the patient to lock the door to guarantee privacy c. Assisting the patient in and out of the tub to prevent dry skin d. Keeping the water temperature very warm because older adults chill easily

c. Rationale: Safe nursing practice requires that the nurse assists a patient with an unsteady gait in and out of the tub. Adding bath oil to the bath water poses a safety risk because it makes the patient and tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43 degrees to 46 degrees Celsius. Older adults have an increased susceptibility to burns due to diminished sensitivity.

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 understands the explanation? a. "There will be 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. "Redness and swelling should decrease after cold treatment." d. "My incision may bleed more when the ice is first applied."

c. Rationale: The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces 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.

A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety? a. Shifting the focus of the interaction to the "process of bathing" b. Washing the face and hair at the beginning of the bath. c. Using music to soothe anxiety and agitation d. Avoiding towel baths or forms of bathing with which the patient is unfamiliar

c. Rationale: The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths. Towel baths, washing under clothes, and bathing "body sections" one day at a time, as well as dry shampoo or "shower cap" shampoos, are additional options.

A nurse is about to bathe a female patient who has an IV in the forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. How will the nurse proceed? a. Quickly disconnecting the IV tubing closest to the patient and thread it through the gown sleeve b. Cutting the gown with scissors to allow arm movement c. Threading the bad and tubing through the gown sleeve, keeping the line intact. d. temporarily disconnecting the tubing from the IV container, threading it through the gown.

c. Rationale: Threading the bag and tubing through the gown sleeve maintains a closed system and prevents contamination. No matter how quickly preformed, any disconnection of IV tubing results in a breach of the sterile system, creating a risk for infection. Cutting a gown is not an alternative except in an emergency.

A patient was in an automobile accident and received a wound across the 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

c. Rationale: Wounds cause emotional as well as physical stress.

MRSA isolation precaution - which patient most at risk?

contact precaution

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? a) Gently rub and massage the area to warm it up b) Notify the health care provider of the findings c) Document the findings in the client's medical record d) Discontinue the therapy and assess the client

d) Discontinue the therapy and assess the client

The nurse is performing an assessment of a client's full thickness pressure injury to the coccyx. The nurse observes that the wound bed is black and will consequently document what finding? a) Erythema b) Gangrene c) Granulation tissue d) Eschar

d) Eschar

A postoperative client is recovering from a bowel resection. While the nurse is assisting the client with a transfer, the client states "I feel like something just popped." After returning the client safely to bed, which is the nurse's best action? a) Reassure the client that this is expected in the immediate post-op period b) Assess the client for signs of an abdominal hernia c) Document the presence of evisceration d) Promptly assess for dehiscence

d) Promptly assess for dehiscence

A Nurse is preforming oral care on a patient who has advanced dementia. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What action will the nurse take next? a. Recommend a consultation with an oral surgeon. b. Communicate the condition to the health care team. c. Gently scrape the oral cavity with tongue depressor. d. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

d. Rationale: If initial oral care results in continued dryness of the oral cavity with crusting, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above; however, mouth care and re-evaluation of the oral cavity is documented. The crusts should not be scraped with a tongue depressor.

A nurse is caring for a patient with an eye infection with a moderate amount of discharge. What is the most appropriate technique for the nurse to use when cleansing this patient's eyes? a. Using diluted hydrogen peroxide on a clean washcloth to wipe the eyes b. Wiping the eye from the outer canthus toward the inner canthus c. Positioning the patient on the opposite side of the eye to be cleansed. d. Cleansing the eye using a different section of the cloth for each stroke until clean.

d. Rationale: The nurse applies gloves for the cleaning procedure, uses water or normal saline, and a clean washcloth or gauze to clean the eyes. After dampening a cleaning cloth with the solution of choice, the nurse wipes once while moving from the inner canthus to the outer canthus of the eye to reduce forcing the debris into the area drained by the nasolacrimal duct. The nurse should turn the cleansing cloth and use a different section for each stroke until eye is clean.

Determine the patient's risk for pressure injury using the Braden scale found in Figure 33-7, based on information in the EHR. EHR 1430 Admission Assessment S: Patient admitted from nursing home for sepsis, confusion, ambulatory dysfunction. B: 87-year old patient, with history of heart failure and hypertension; comes to ED with shortness of breath and yellow sputum. A: Lungs with crackles, pale, short of breath on exertion, pulse oximetry 88%, skin fragile. Bedrest maintained. States has not eaten nor drank fluids for last 36 hours; incontinent of small amount of urine x 2. Responding to painful stimuli, not participating in turning or care. R: Need orders for oxygen, sputum culture, activity level. Consider IV fluids. J. Smith RN. a. No risk b. Moderate risk c. High risk d. Very high risk

d. Rationale: The patient is at very high risk for pressure injury. This patient responds only to painful stimulate (1); is occasionally moist (3); is bedridden (1); has not eaten (1), and requires maximum assistance for moving (1) for a total of 7 points. The Braden scale scoring is; a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to 14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk. In addition, nurses use clinical judgement to incorporate risk factors and/or other health problems into preventative interventions.

A nurse is developing education for nurses and UAPs related to prevention of pressure injuries for residents in a long-term care facility. Which action to prevent pressure injury will the nurse delegate to the UAP? a. Maintaining the head of the bed elevated consistently b. Massaging over bony prominences c. Repositioning bedbound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin

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

diphtheria

droplet precaution

chain of infection

infectious agent reservoir portal of exit mode of transmission portal of entry susceptible host

The nurse is preparing a client in airborne precautions for severe acute respiratory syndrome (SARS) to be transported to radiology. Which intervention will the nurse select to transport the client? Select all that apply. place a mask on the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet

place a mask on the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet

Which client would the nurse consider the most infectious?

prodromal stage

neutropenic

protective environment

virus - size - examples

smallest common cold, hepatitis B and C, AIDS

2 phases of inflammation

vascular: small blood vessels constrict; followed by vasodilation of arterioles (this increase blood flow results in redness and heat) ; histamine released -- increased permeability (swelling) cellular stage: WBC move to area; neutrophils engulf the organism

MDRO Risk Factors

•Previous exposure to antibiotics •Impaired body defenses •Severe illness •Invasive procedures or devices •Repeated hospitalization •Advanced age