Foundations Exam 1

The nurse is caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states, "My pain medication is effective, but will this pain ever get better and go away?" Which response is correct? a. "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." b. "It is unusual for you to still have severe pain. I will contact your surgeon." c. "If the prescribed analgesics are controlling the pain, we do not worry about the severity of the pain." d. "If the pain does not subside by this time tomorrow, you will need to be screened for the development of chronic pain."

"Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe."

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. "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." b. "This procedure can be safely preformed using clean technique if care is taken not to touch the wound." c. "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)." d. "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

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

collagen dressings

* gel, past, powder, granules, sheets, sponges derived from animal sources (cow or pig) * assists with stopping bleeding * helps recruit cells into the wound and stimulates their proliferation to facilitate healing * indications - clean moist wounds * examples - Biostep, Cellerate RX, NU-GEL, Promogran

pressure injury stage 1

- Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

stage 3 PI treatment

- clean or debride -provide nutritional supplements -administer analgesics -provide antimicrobials

stage 4 PI treatment

- clean or debride -perform nonadherent changes every 12 hrs -provide nutritional supplements -administer analgesics -provide antimicrobials

stage 1 pressure injury treatment

- relieve pressure - encourage movement - use pressure relieving devices -keep client dry, clean , well nourished, and hydrated

Factors affecting wound healing

-Increased age -loss of skin turgor (elasticity) -skin fragility -slower tissue regeneration -decrease in absorption of nutrients -decrease in collagen - impaired immune system functions - dehydration

Primary intention healing

-Little or no tissue lost - edges are approximated (surgical incision) - heals rapidly - low risk of infection -no or minimal scarring

proliferation phase of wound healing

-begins on 3rd, 4th day - lasts 2-3 weeks -macrophages continue to clear the wound of debris and stimulate fibroblasts which synthesize collagen -new capillary networks formed to provide oxygen and nutrients to support collagen and for further synthesis of granulation tissue -tissue is deep pink -full thickness wound begins to close by contraction as new tissue is grown -scarring influenced by degree of stress on wound

maturation phase of wound healing

-final phase begins about 3 weeks from injury -may take up to 2 years -collagen is remodeled , making the healed wound stronger. -scar maturation, or remodeling -scar tissue slowly thins and becomes paler

Secondary intention healing

-loss of tissue -wound edges are largely separated - longer healing time increase risk for infection -scarring -heals by granulation

stag2 pressure injury treatment

-maintain a moist healing environment -promote natural healing -provide nutritional supplements -administer analgesics

Hemostasis stage of wound healing

-occurs immediately after initial injury -blood clotting begins

Tertiary intention healing

-widely separated -deep -spontaneous opening of a previously closed wound -infection and edema (swelling caused due to excess fluid)

Dehiscence

A separation of layers, usually of a surgical wound

Self-adhesive, transparent film

A temporary "second skin" ideal for small, superficial wounds

Hydrocolloid dressing

An occlusive dressing that swells in the presence of exudate; composed of gelatin and pectin, it forms a seal at the wound's surface to prevent evaporation of moisture from the skin

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? a/ Avoid using irrigation to clean the wound before changing the dressing. b. Apply dry gauze to the wound and carefully apply saline to saturate it. c. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. d. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes

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.

Pressure ulcers

Compromised circulation secondary to pressure or pressure combined with friction

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

Connective tissue

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

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

Do you experience incontinence?

stage 3 pressure ulcer

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

stage 4 pressure injury

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.

Wound healing phases

Homeostasis (may be included in the inflammatory phase, proliferation phase, maturation phase,

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen? a. Impaired Skin Integrity related to open wound b. Pain related to wound sustained by knife c. Knowledge Deficit regarding wound care related to laceration d. Risk for Infection related to wound

Impaired skin integrity related to open wound

Wound complications

Infection Hemorrhage Dehiscence and evisceration Fistula formation (abnormal passage from an internal organ or vessel to the outside body or from one internal organ or vessel to another.

venous ulcers

Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction

Diabetic ulcers

Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure

Types of wounds

Intentional or unintentional Open or closed Acute or chronic

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client? a. Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs b. Placing the client in the supine position with a pillow under the knees c. Placing the client in a side-lying position with a pillow between the lower legs d. Placing the client in a wheelchair with the back of the feet resting against the heel loops

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

Functions of the skin

Protection, Thermoregulation, Sensation, Vitamin D synthesis, psychosocial, immunologic, elimination, absorption

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? a. white b. red c. yellow d. blue-grey

RED

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain?

Secure the drain to the client's gown with a safety pin below the level of the wound.

Age related changes to older adults

Skin becomes thinner, dryer. Cell renewal is shorter, skin loses elasticity.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? a.Stage I b.Stage II c.Stage III d.Stage IV

Stage II

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

That is necrotic tissue, which must be removed to promote healing

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? a. The nurse uses wet-to-dry dressings continuously. b. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. c. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. d. The nurse packs the wound cavity tightly with dressing material.

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

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 lies on wrinkled sheets d. a client who must remain on the back for long periods of time

a client sitting in a chair who slides down

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? a. Desiccation b. Maceration c. Necrosis d. Evisceration

a. dessication

fistula

abnormal passageway between two organs or between an internal organ and the body surface

woven gauze

absorbs exudate from the wound

Factors Placing a Person at Risk for Skin Alterations

age, homosexuality, occupation, body piercings, dehydration or malnutrition, reduced sensation, diabetes mellitus, GI series, bed rest, casts, medications, radiation therapy, aquathermia unit

A client's risk for the development of a pressure injury is most likely due to which lab result? a. albumin 2.5 mg/dL b. glucose 110 mg/dL c. hemoglobin A1C 7% d. sodium 135 mEq/L

albumin 2.5mg/dL

closed wound

an internal injury with no open pathway from the outside examples include ecchymosis and hematomas

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

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

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? a. "Be sure to take at least two showers daily to remove all microorganisms from the skin." b. "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." c. "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." d. "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

avoid soaps with artificial ingredients or fragrances, as milder soaps are safer

A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For what type of injuries would the nurse be alert? Select all that apply. a. Broken left ankle b. Bruising c. Soft tissue damage d. Concussion e. Abrasions f. Dehydration

broken left ankle, bruising, soft tissue damage, concussion, abrasions

Which individuals are at most risk for skin wounds/irritation

children under 2 years, obese, thin, elderly people

serous drainage

clear, watery fluid

Hydrogels

composition is mostly water. Gels after contact with exudate, promoting debridement and cooling. -used for infected deep wounds

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

contusion

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a. corticosteroids b. antihypertensive drugs c. potassium supplements d. laxatives

corticosteroid

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? a.The nurse elevates the foot of the bed. b.The nurse uses a ring cushion to protect reddened areas from additional pressure. c.The nurse increases the amount of time the head of the bed is elevated. d.The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

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

pressure injury

damage of the skin and the subcutaneous tissue caused by prolonged pressure usually occurs over bony prominences

Nonadherent material (dressing)

does not stick to the wound

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

evisceration

factors in pressure injury development

external pressure, friction and shear

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? a. circular turn b. spiral-reverse turn c. spica turn d. figure-of-eight turn

figure-of-eight-turn

red color of open wound

healthy regeneration of tissue

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? a. transparent film b. hydrocolloid c. hydrogel d. alginate

hydrocolloid

risk for pressure ulcer development

immobility nutrition and hydration moisture mental status age

open wounds

incisions, lacerations, abrasions, and puncture wounds

arterial ulcers

injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis and thrombosis

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. a. Insert a swab into the wound. b. Press and rotate the swab several times over the wound surfaces. c. Place the swab in the culture tube when done. d. Use the same swab for both wound sites. e. Touch the swab to the intact skin at the wound edges. f. Tap the outside of the culture tube with the swab before placing it in the tube.

insert the swab into the wound, press and rotate the swab several times over the wound surfaces, place the swab in the culture tube when done

Sanginous drainage

it is thick and appears reddish. brighter drainage indicates active bleeding. darker drainage indicates older bleeding/drainage.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: a. milia. b. prickly heat. c. acne vulgaris. d. lanugo.

milia

Purosanguineous drainage

mixed drainage of pus and blood

serosanguineous drainage

mixture of serum and red blood cells. light pink to blood tinged

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client? a. Monitor intake and output. b. Assess the coccyx area for blanching. c. Monitor the client for nausea. d. Assess mental status.

monitor intake and output

granulation tissue

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

Alginate dressing

nonadherent dressing that conform to the wound's shape and absorb exudate

unstageable pressure injury

obscured full-thickness skin and tissue loss within the ulcer cannot be confirmed because it is obscured by slough or eschar

Inflammatory phase characterized by

pain, heat, redness, and swelling of the cite Patients response: mildly elevated temp, increased wbc's, general malaise

stage 2 pressure injury

partial thickness skin loss with exposed dermis - the wound visible is pink or red , moist. -Slough(white or yellow dead skin), eschar(dark, crusty tissue), granulation and adipose tissue is not visible. It can appear as intact or ruptured blister

deep tissue pressure injury

persistent non-blanchable deep red, maroon, or purple discoloration

black color of open wound

presence of eschar that hinders healing and requires removal

yellow color of open wound

presence of purulent drainage and slough

The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force? a. preventing the client from sliding in bed b. pulling the sheets to reposition the client every 2 hours c. improving the client's hydration d. pulling the client up from under the arms

preventing the client from sliding in the bed

When does scarring, or fibrosis, occur?

proliferation phase

Evisceration

protrusion of viscera through an incision

purluent drainage

results of infection. it is thick, may be yellow, tan , green or brown.

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? a. primary intention b. maturation c. secondary intention d. tertiary intention

secondary intention

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? a. serous b. sanguineous c. serosanguineous d. purulent

serosanguineous

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?

stage III

Inflammatory phase of wound healing

starts after homeostasis and last about 2-3 days. -blood clot- controlling the bleeding with vasoconstriction, retraction of blood vessels, fibrin accumulation and clot formation. -white blood cells (deliver oxygen), -leukocytes ingest bacteria and cellular debris -Macrophages they not only ingest bacteria but release growth factors for epithelial cells and new blood vessel.

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? a. Stop removing staples and inform the surgeon b. Apply adhesive wound closure strips after each staple is removed. c. Apply an occlusive pressure dressing after removing the staples. d. Stop removing staples and apply an abdominal pad over the incision.

stop removing staples and inform the surgeon

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? a. Epidermis b. Dermis c. Subcutaneous tissue d. Muscle layer

subcutaneous tissue

acute wound

such as surgical incisions, usually heal within days to week (risk of infection is low)

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? a. Supports the area around the wound b. Maintains a moist environment c. Keeps the wound clean d. Reduces swelling and inflammation

supports the area around the wound

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? a. Tearing of the skin and tissue with some type of instrument; tissue not aligned b. Cutting with a sharp instrument with wound edges in close approximation with correct alignment c. Tearing of a structure from its normal position d. Puncture of the skin

tearing of a structure from its normal position

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

transparent

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

use pillow to maintain a side-lying position

Damp to damp 4-inch by 4-inch dressings

used to mechanically debride a wound until granulation tissue starts to form in the wound bed. Must keep moist at all times to prevent pain and disruption of wound healing

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. a. "Very little scar tissue will form." b. "This is a simple reparative process." c. "The margins of your wound are widely separated." d. "Your wound will be purposely left open for a time." e. "Your wound edges are right next to each other."

very little scar tissue will form, this a simple reparative process, your wound edges are right next to each other

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? a. Gentle cleansing b. Wound irrigation c. Debridement d. Apply moist dressing

wound irrigation

Examples of chronic wounds

wounds related to diabetes, arterial or venous insufficiency, and pressure injuries

chronic wounds

wounds that exceed the expected length of recovery, risk of infection is increased (wound edges are not approximated)