Fundamentals Ch. 32

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?

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

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?

"Dehiscence is when a wound has partial or total separation of the wound layers."

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?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

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

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

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

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

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?

As a stage I pressure injury

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

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

Discontinue the therapy and assess the client.

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

Fish

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? Keep the swab and the inside of the culture tube sterile. Utilize the culture swab to obtain cultures from multiple sites. Stroke the culture swab on surrounding skin first. Cleanse the wound after obtaining the wound culture.

Keep the swab and the inside of the culture tube sterile.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

Local capillary pressure must be lower than external pressure.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

Milia

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down

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

To splint the area when engaging in activity

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True/False

True

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. true/false

True

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

an obese woman with a history of type 1 diabetes

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound applying sterile dressings with normal saline over the protruding organs and tissue

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

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

corticosteroids

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence

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? hemorrhage fistula evisceration dehiscence

evisceration

Stage 4 pressure ulcer

full-thickness skin loss with extensive destruction (visible bone, muscle or ligament)

Stage 2 pressure ulcer

partial-thickness skin loss (blister)

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed

Stage 1 pressure ulcer

skin intact, reddened, non-blanchable area

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

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?

stage IV

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

to apply sunscreen when exposed to ultraviolet rays.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside.

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

Connective 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?

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

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown May vary from brown or black to cherry red or pearly white; bullae may be present A superficial partial-thickness burn, which can appear dry and leathery Superficial, which may be pinkish or red with no blistering

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

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?

incision

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply. a) Place client in low Fowler's position b) Pack the wound with iodoform gauze c) Use sterile techniques d) Cover wound with a gauze moistened with normal saline e) Reinsert protruding structures and apply a pressure dressing

using sterile technique covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

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 transparent film

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings? Diffuse fungal infection accompanied by pruritus Superficial abscess accompanied by pruritus Superficial contusion accompanied by pruritus Diffuse dermatitis accompanied by pruritus

Diffuse dermatitis accompanied by pruritus

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?

Implement a 2-hour repositioning schedule

Stage 3 pressure ulcer

full-thickness skin loss, not involving underlying fascia

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply. Leave the drain open for 5 to 7 minutes to ensure full drainage. Administer analgesia before changing the dressing around the drain, if needed. Perform hand hygiene and put on goggles before emptying the drain. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it. Use a gauze pad to clean the drain outlet after emptying it.

-Administer analgesia before changing the dressing around the drain, if needed. - Use a gauze pad to clean the drain outlet after emptying it. -Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

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. a. No finger numbness or tingling b. Fingers with quick capillary refill c. Cyanosis d. Warm hand e. Decreased radial pulse

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

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 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. Evisceration c. Necrosis d. Maceration

a. DesiccationRationale Desiccation is localized wound dehydration. Maceration is localized wound over hydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

use pillows to maintain a side-lying position as needed