Chp 38 Wound care

The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care?

Clean dressings and no touch technique

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patients anxiety?

Explain the procedure.

When irrigating a wound, how would the nurse know the right amount of pressure to apply?

Follow the general rule of keeping the pressure between 4 and 15 psi.

What is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?

Further assess the patient and the wound.

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer

Healing stage III pressure ulcer

Which wound would be allowed to heal by secondary intention?

Infected hysterectomy incision

A patient's full-thickness wound is establishing a clean wound bed and obtaining bacterial balance. This patient is in which phase of wound healing?

Inflammation phase

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to

Inspect the wound for bleeding.

An elderly patient who resides in a nursing home is suffering from a respiratory infection. During the illness, the patient has become incontinent of both urine and stool. The nursing staff used a special cleanser on the perineum, put a moisture barrier on the exposed area, and used absorbent briefs to prevent the skin from becoming soft because of the moisture. What was the staff trying to prevent?

Maceration

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased

Protein.

Which of the following would be the most important piece of assessment data to gather with regard to wound healing?

Pulse oximetry assessment

A patient is wearing an abdominal binder after abdominal surgery. What does the nurse need to assess and document about the patient?

Respiratory status

Which nursing observation would indicate that a wound healed by secondary intention?

Scarring can be severe.

The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by

Secondary intention.

A patient has developed a decubitus ulcer. What laboratory data would be important to gather?

Serum albumin

A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed owing to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)

a.Dehiscence b.Evisceration e.Hemorrhage

On admission a patient is noted to have an alteration in skin integrity on the right heel. The nurse uses the Braden Scale. Which areas will the nurse assess when using this scale? (Select all that apply.)

a.Mobility b.Nutrition d.Friction and shear e.Sensory perception

A patient has a wound to the left lower extremity that has minimal exudates, and granulation tissue and collagen formation. The nurse identifies the healing phase of this wound as:

proliferative phase

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing?

23

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of

Full-thickness wound repair

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk?

Gentle cleaners and thorough drying of the skin

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair?

Granulation

The wound bed of a patient's pressure ulcer is red. What does this finding indicate to the nurse?

Granulation tissue

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient?

Halogen light

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by

Primary intention.

A pre-teen quadriplegic patient was admitted with pressure ulcers to both ankles. The nurse should assess which parameters for a wound assessment? (Select all that apply.)

a.Size b.Viable versus nonviable tissue c.Tissue type involvement e. Anatomical location

A severely overweight patient has returned to the unit after having major abdominal surgery. When the nurse enters the room, it is evident that the patient has moved or coughed and the wound has eviscerated. The nurse should immediately:

place sterile towels soaked in saline over the area.

How would the nurse safely apply an enzyme debridement ointment?

Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.

Before performing a wound assessment, which nursing action would reduce the patient's risk for infection?

Applying clean gloves

A patient will require the application of a binder to provide support to the abdomen. When applying the binder, the nurse uses the principle that the:

patient must maintain adequate ventilatory capacity

The primary health care provider has ordered the patient to wear an elastic bandage to the left ankle owing to a severe strain. The nurse has instructed the patient on proper application of the elastic bandage. Which statement indicates the patient needs more teaching?

"I need to wrap the bandage toward my toes."

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure ulcers in an older adult patient?

1. Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure ulcers in an older adult patient?

Which device is used for wound irrigation?

19-Gauge needle attached to a 35-mL syringe

The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s).

4

An elderly patient has been admitted to the hospital for pneumonia. Which factor could put this patient at risk for a pressure ulcer?

A diet low in protein

Which patient is best suited for heat therapy?

A patient with low back pain

When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?

After removing the original dressing materials and performing hand hygiene a second time

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include

Alteration in level of consciousness.

A nurse is working with a patient who has a stage 3, clean pressure injury with significant exudate. The nurse anticipates that which of the following dressings will be used?

Calcium alginate dressing

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurses next best step?

Call the physician; a blockage is present in the tubing.

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes

Debridement of the wound.

The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included?

Cleansing in a direction from the least contaminated area

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?

Complaint by patient that something has given way

The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?

Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results.

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain?

Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention.

The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

Diabetes mellitus

A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?

Drainage that was not present previously

The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement?

Elevate right knee and apply ice.

The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient?

Encourage thorough handwashing of all individuals caring for the patient.

The nurse is caring for a patient with a necrotic hip wound. Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?

Hydrogel

The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following?

I am ready for my bath and linen change as soon as possible

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage

I.

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage

II.

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses?

Impaired skin integrity

The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question?

Irrigate with hydrogen peroxide.

A surgical wound requires a hydrogel dressing. What is the primary advantage of a hydrogel dressing?

It provides moisture needed for wound healing.

Which measurements would the nurse use to calculate the surface area of a patient's pressure ulcer?

Length and width

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?

Less than 2 hours

The nurse is preparing to change a large wound dressing on the patient's buttock. Which intervention should the nurse address first?

Medicate appropriately before performing the dressing change.

An elderly patient is admitted to the hospital for a bowel obstruction. The patient is immobile and the nurse notices that there is a reddened area on the right heel. When the nurse presses on the area it does not turn lighter in color. How should the nurse document the tissue condition?

Nonblanchable hyperemia

The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate?

Nonpowered redistribution air mattress

The nurse is completing an assessment of the skins integrity, which includes

Pressure points.

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a

Registered dietitian.

Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?

Reporting the presence of wound odor

A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus. The admitting nurse notes that an area of redness on the right malleolus is nonblanchable. The nurse correctly identifies this pressure ulcer at what stage?

Stage I

An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework. During a bath, the assistive nursing personnel noticed that there was a large blister on the patient's right heel. The patient denies knowledge of having injured self. It was reported to the nurse who correctly documented it as what stage of a pressure ulcer?

Stage II

A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan. The admitting diagnosis is failure-to-thrive. On admission, the patient was found to have a wound on the right scapula. The nurse noted full-thickness tissue loss with tunneling, but did not note any bone, tendon, or muscle. This was correctly identified as what stage of a pressure ulcer?

Stage III

A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone. The nurse should document this pressure ulcer at what stage?

Stage IV

When a patient has full-thickness loss but the depth is unknown, how should the nurse classify this pressure ulcer?

Unstageable

The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder?

The binder supports the abdomen.

The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing?

The incision has a mass, bluish in color.

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?

The patient has fecal incontinence

The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient?

The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound.

Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound?

Use appropriate personal protective equipment (PPE).

Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer?

Use appropriate personal protective equipment.

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?

Using a new gauze pad for each stroke while cleansing the wound

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient?

Utilize a transfer sliding board and assistance to slide the patient into the new position

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's wound?

Wait until the health care provider orders the removal of the surgical dressing.

Which therapy should the nurse choose that will improve a patient's circulation, relieve edema, and promote concentration of pus and drainage

Warm moist compresses

Which action should the nurse avoid before irrigating a patient's foot wound?

Warm the irrigant to body temperature in the microwave.

A patient is being seen in the Emergency Department for a puncture wound on the foot. The patient was walking in a construction site, but is unsure what caused the injury. During the initial assessment the nurse determines if the patient has received a tetanus toxoid injection within which time frame?

Within the last 10 years

A nurse is working in a physician's office and is asked by one of the patients when heat or cold should be applied. In providing an example, the nurse identifies that cold therapy should be applied for the patient with:

a newly fractured ankle.

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)

a. Can you easily change your position? b. Do you have sensitivity to heat or cold? c. How often do you need to use the toilet? d. Is movement painful?

The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurses responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.)

a. Inspecting the skin for abrasions and edema b. Covering exposed wounds c. Assessing condition of current dressings d. Assessing the skin at underlying areas for circulatory impairment

The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.)

a. Nutrition c. Tissue perfusion d. Infection f. Age

Assistive personnel ask the nurse the differences between wound healing by primary and secondary intention. The nurse's best response is that healing by primary intention occurs when the skin edges:

are approximated.

The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.)

b. Hyperemia c. Induration d. Blanching e. Temperature of skin

The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.)

b. Prevent injury to the skin and tissues. d. Reduce injury to the skin. e. Reduce injury to the underlying tissues. f. Restore skin integrity.

A patient with a knife protruding from his upper leg is taken into the emergency department. A nurse is waiting for the physician to arrive when a newly hired nurse comes to assist. The nurse delegates the new staff nurse to do all of the following as soon as possible except:

emove the knife to cleanse the wound.

A nurse is aware that malnutrition places a patient at a greater risk for tissue damage. The patient with the greatest risk is the individual who:

experienced a 7% weight loss in the last month.

To avoid pressure injury for an immobilized patient at home, a nurse recommends a surface to use on the bed. A surface type that is low cost and easy to use in the home is a(n):

foam overlay.

For a patient in the extended care facility who has a risk for pressure injuries, a nurse will implement:

maintenance of a position while in bed at 30 degrees or lower

The agent that is most effective and safest for cleaning a granular wound is

normal saline.

For a patient's optimal nutritional intake that will promote formation of new blood vessels and collagen synthesis, the nurse plans to teach the patient to include a sufficient intake of:

proteins.

A patient has a large wound to the sacral area that requires irrigation. The nurse explains to the patient that irrigation will be performed to:

remove debris from the wound.

After neurosurgery, a nurse assesses the patient's bandage and finds that there is fresh bleeding coming from the operative site. The nurse describes this drainage to the surgeon as:

sanguineous

The nurse notices that the skin surrounding a wound appears macerated. The nurse should

select a different dressing

A patient's draining wound is pale and watery with a combination of plasma and red cells. How should the nurse document this finding?

serosanguineous drainage

The student nurse asks a nursing assistive personnel (NAP) to help move a patient up in bed. The student nurse instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation?

shear

A nurse is completing an assessment of the patient's skin integrity and identifies that an area is a full-thickness loss of skin with adipose tissue, slough, and eschar visible. The nurse identifies this stage of pressure injury as:

stage 3.

A patient has a surgical wound on the right upper aspect of the chest that requires cleansing. The nurse implements appropriate aseptic technique by

starting at the drainage site and moving outward with circular motions.

A nurse is assessing a patient's superficial wound and notices that it has very minimal tissue loss and drainage. There are a number of dressings that may be used according to the protocol on the unit. The nurse selects:

transparent film.

The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for

trauma.

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected?

ulture and sensitivity test

A nurse is working with an older adult patient in an extended care facility. While turning the patient, the nurse notices that there is a reddened area on the patient's coccyx. The nurse implements skin care that includes

using a mild cleansing agent, drying, and applying a protective moisturizer.

The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patients Braden scale total score?

20

The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign?

Ineffective tissue perfusion

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is

Pressure.

A patient who has undergone a colectomy is demonstrating wound healing. The nurse correctly identifies the wound phase characterized by synthesis of collagen fibers as which of the following?

Proliferative phase

The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patients willingness and ability to increase mobility, which intervention is most important for the nurse to complete?

Provide analgesic medication as ordered.

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first?

Provide analgesic medications as ordered.

A postoperative patient visits the ambulatory care clinic complaining of just "not feeling well." The patient has an elevated temperature. Which assessment finding should indicate to the nurse that the wound has become infected?

Purulent drainage coming from the incision area

The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.)

a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel

A patient has experienced a traumatic injury that will require applications of heat. The nurse implements the treatment based on the principle that:

patient response is best to minor temperature adjustments.