Fundamental Chapter 32: Skin Integrity and Wound Care
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? A) Assess the client's wound and vital signs. B) Administer the prescribed analgesic. C) Notify the health care provider of the pain. D) Document the pain and vital signs.
A) Assess the client's wound and vital signs. Explanation: First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.
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) Discontinue the therapy and assess the client. B) Notify the health care provider of the findings. C) Document the findings in the client's medical record. D) Gently rub and massage the area to warm it up.
A) Discontinue the therapy and assess the client. Explanation: The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.
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?"
A) "Do you experience incontinence?" Explanation: The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.
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."
A) "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." Explanation: Surgical incisional pain is usually most severe for the first 2 to 3 days and then progressively diminishes. It is imperative that nurses teach clients about the progression of pain postsurgery. The client should still be assessed for pain and the pain scale should be documented in the client's medical record. The development of chronic pain is persistent pain after 6 months.
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? A) "Very little scar tissue will form." B) "This is a complex reparative process." C) "The margins of your wound are not in direct contact." D) "The surgeon will leave your wound open intentionally for a period of time."
A) "Very little scar tissue will form." Explanation: Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.
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) "Your wound will heal slowly as granulation tissue forms and fills the wound." B) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." C) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." D) "As soon as the infection clears, your surgeon will staple the wound closed."
A) "Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.
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
A) Impaired Skin Integrity related to open wound Explanation: Impaired skin integrity best describes the minor laceration. While the other diagnoses, Pain, Knowledge Deficit, and Risk for Infection, are all possible as a result of the laceration, there is no indication in the scenario that they are the case.
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) Reduce the time interval between dressing changes. B) Assure that the packing material is completely saturated when placed in the wound. C) Use less packing material. D) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.
A) Reduce the time interval between dressing changes. Explanation: Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.
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.
A) Stop removing staples and inform the surgeon Explanation: If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? A) To splint the area when engaging in activity B) To ambulate using a cane or walker C) To remain in bed for the next 4 hours D) To turn the head away from the area whenever coughing
A) To splint the area when engaging in activity Explanation: To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.
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) a client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure injury from shearing forces would be a client sitting in a chair who slides down.
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? A) a sterile, flexible applicator moistened with saline B) a small plastic ruler C) a sterile tongue blade lubricated with water soluble gel D) an otic curette
A) a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.
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 in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? A) a transparent film B) a gauze dressing precut halfway to fit around the IV line C) a dressing with a nonadherent coating D) a gauze dressing premedicated with antibiotics
A) a transparent film Explanation: Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms. Gauze dressings--precut, with an adherent coating, premedicated with antibiotics--do not allow the nurse to visualize the site without partially or completely removing the dressing.
The nurse would recognize which client as being particularly susceptible to impaired wound healing? A) an obese woman with a history of type 1 diabetes B) a client whose breast reconstruction surgery required numerous incisions C) a man with a sedentary lifestyle and a long history of cigarette smoking D) A client who is NPO (nothing by mouth) following bowel surgery
A) an obese woman with a history of type 1 diabetes Explanation: Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.
The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. A) an older adult who is confined to bed B) a client with a peripheral vascular disorder C) a client who is obese D) a client who eats a diet high in vitamins A and C E) a client who is taking corticosteroid drugs F) a 10-year-old client with a surgical incision
A) an older adult who is confined to bed B) a client with a peripheral vascular disorder C) a client who is obese E) a client who is taking corticosteroid drugs Explanation: There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure injury formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client. A client who eats a diet high in vitamins A and C would not be at risk for delayed wound healing. A 10-year old client with a surgical incision would not be at risk for delayed wound healing.
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
A) contusion Explanation: A contusion is an injury to soft tissue, so this is what the nurse expects to see on the basis of the teacher's description of the incident. A puncture involves an opening in the skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripping of the surface layers of skin. In an avulsion injury, large areas of skin and underlying tissues have been stripped away.
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
A) corticosteroids Explanation: Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.
A full-thickness or third-degree burn develops a leathery covering called a(an): A) eschar. B) static. C) abrasion. D) erythema.
A) eschar. Explanation: The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? A) "Dehiscence is not anything that you need to worry about." B) "Dehiscence is when a wound has partial or total separation of the wound layers." C) "Dehiscence is a total separation of the wound with protrusion of the viscera through it." D) "Dehiscence is the softening of tissue due to excessive moisture."
B) "Dehiscence is when a wound has partial or total separation of the wound layers." Explanation: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound.
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? A) "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." B) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." 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) "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."
B) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.
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) Allow the wound and intestinal contents to remain open to air. B) Apply saline solution-moistened gauze over the protruding area. C) Pack the wound with gauze pads and a dry sterile dressing. D) Inform the client that this is an expected occurrence and not to worry.
B) Apply saline solution-moistened gauze over the protruding area. Explanation: The first thing the nurse will do is cover the protruding intestine with a saline solution-moistened gauze. The nurse will then notify the health care provider of wound evisceration. If the protruding intestine is left open to the air, it may cause drying of the fragile tissue and necrosis to the area. The nurse should not pack anything into the wound since foreign body retention may cause complications at a later time if the gauze is not recovered. The occurrence of wound evisceration is not an expected finding and may be serious depending upon whether the protruding area is viable.
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? A) Glasgow scale B) Braden scale C) FLACC scale D) Morse scale
B) Braden scale Explanation: The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glasgow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls.
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) Pasta salad B) Fish C) Banana D) Green beans
B) Fish Explanation: To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much
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
B) Stage II Explanation: A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.
A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? A) Scarring, sutures, and wound care B) Tetanus, infection, wound care, and pain control C) Prevention of recurring infection, ability to work, and wound care D) Tetanus, being able to walk, and scarring
B) Tetanus, infection, wound care, and pain control Explanation: Chances are the client knows that stepping on a nail could lead to a serious complication or illness, even if the client cannot remember or does not know about tetanus or infections. How to care for the wound is usually something clients will want to know before being discharged. The client in this scenario is reporting pain, so pain control will be one of the concerns. It is unlikely that the client will be worried about scarring on the bottom of the foot or sutures due to it being a puncture. The client is still walking, although in pain and with a limp, it would be unlikely the client would be concerned about being able to walk. More than likely, the client has already figured out the injury may not have occurred or would not be as bad had he or she been wearing shoes, so the nurse would not anticipate the need for preventative education.
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
B) hydrocolloid Explanation: Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.
The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? A) stage I B) stage II C) stage III D) stage IV
B) stage II Explanation: The area of redness and blister formation indicate that the client is experiencing a stage II pressure injury. A stage I pressure injury is intact but reddened. A stage III pressure injury has a shallow skin crater that extends to the subcutaneous tissue. A stage IV pressure injury is severe; the tissue is deeply ulcerated and exposes muscle and bone with the presence of necrotic tissue likely.
A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: A) to provide a sinus tract for drainage. B) to provide drainage for bile. C) to decrease dead space by decreasing drainage. D) to divert drainage to the peritoneal cavity.
B) to provide drainage for bile. Explanation: A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? A) gauze B) transparent C) hydrocolloid D) bandage
B) transparent Explanation: The nurse should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. A hydrocolloid dressing helps keep the wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.
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
B) use pillows to maintain a side-lying position as needed Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? A) "I should keep this on my ankle until it is numb." B) "I must wait 15 minutes between applications of cold therapy." C) "I will put a layer of cloth between my skin and the ice pack." D) "I can let this stay on my ankle an hour at a time."
C) "I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.
The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? A) "You will receive medication through this device." B) "Drainage will occur by gravity and capillary action." C) "It provides a way to remove drainage and blood from the surgical wound." D) "The bulb-like system will stay in place permanently after your mastectomy."
C) "It provides a way to remove drainage and blood from the surgical wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical site. Drainage in this system is aided by low suction, not by gravity or capillary action. It does not provide a route for medication administration, nor does it stay attached permanently.
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) Herniation of the wound C) Dehiscence of the wound D) Evisceration of the viscera
C) Dehiscence of the wound Explanation: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents. Reference:
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) Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. B) Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. C) Rotate the swab several times over the wound surface to obtain an adequate specimen. D) Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.
C) Rotate the swab several times over the wound surface to obtain an adequate specimen. Explanation: The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.
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
C) Tearing of a structure from its normal position Explanation: An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.
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.
C) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. Explanation: A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? A) avulsion B) abrasion C) incision D) laceration
C) incision Explanation: An incision is a clean separation of skin and tissue with smooth, even edges. Therefore the nurse documents the finding as an incision. In an avulsion, large areas of skin and underlying tissue have been stripped away. An abrasion involves the stripping of the surface layers of skin. A laceration is a separation of skin and tissue with torn, irregular edges. Therefore the nurse does not document the finding as an avulsion, abrasion, or laceration.
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
C) serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink or pink-yellow. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.
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? A) gauze B) adhesive strips with eyelets C) transparent D) hydrocolloid
C) transparent Explanation: Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist.
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."
D) "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." Explanation: The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.
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) Cleanse the wound after obtaining the wound culture. B) Stroke the culture swab on surrounding skin first. C) Utilize the culture swab to obtain cultures from multiple sites. D) Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
D) Keep the swab and the inside of the culture tube sterile prior to collecting the culture. Explanation: The swab and the inside of the culture tube should be kept sterile prior to the procedure. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? A) The nurse uses a safety pin to attach the pad to the bedding. B) The nurse covers the heating pad with a heavy blanket. C) The nurse places the heating pad under the client's neck. D) The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
D) The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. Explanation: The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client's neck. The nurse would not cover the heating pad with a heavy blanket.
A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has prescribed fly larvae to debride the wound. Which type of debridement does the nurse understand has been prescribed? A) autolytic debridement B) surgical (sharp) debridement C) enzymatic debridement D) mechanical debridement
D) mechanical debridement Explanation: The use of fly larvae (maggot therapy) is a form of mechanical debridement, because their mandibles and rough body surface scratch the necrotic tissue. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Surgical (sharp) debridement is the removal of necrotic tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments.
