Fundamentals of Nursing Chapter 32 PrepU Practice

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?

"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.

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?

"It allows removal of blood and drainage from the surgical wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical wound. It does not decrease the pain level, nor does it stay attached permanently. The nurse empties the drain but does not place medication inside it.

The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care for dressing changes?

Increases the risk of infection by contaminating the wound Explanation: Using the mouth to blow air into a wound bed or to dry the wound edges does not adhere to the standards of care or of ethics for nurses. This action will increase the risk of wound contamination and the wound is more likely to become infected as our mouths and the air we blow out harbors many kinds of bacteria that can adhere to the wound and increase the risk for infection and contamination. Every effort should be taken into consideration to use sterile equipment, solutions and medical aseptic, or clean technique to remove old dressings. Coolness to a site decreases blood flow and to heal a wound more blood flow to the site assists with healting and reducing the risk of infection. Blowing on a wound bed may cause a uncomfortable sensation to the skin or funny sensation but it will not reduce the risk of the infection. The effect of the blowing sensation and contaminants in to the wound bed demonstrates non-adherence to the standards of safe and effective wound care and management.

A client who was injured when he stepped on a rusted nail visits the health care facility. How should the nurse describe this wound?

Puncture Explanation: The nurse should describe this wound as a puncture. A puncture wound can be described as an opening in the skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object. An abrasion is a wound in which the surface layers of skin are scraped away. An avulsion is the stripping away of large areas of skin and underlying tissue, leaving cartilage and bone exposed. An ulceration is a shallow crater in which skin or mucous membrane is missing.

A nurse caring for a client who has a surgical wound after a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?

There is an unintentional separation of the wound. Explanation: With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together. Edema is an accumulation of fluid in the interstitial tissue. Redness or inflammation of an area as a result of dilation is erythema.

A nurse working in long-term care is assessing residents at risk for the development of a pressure injury. Which one would be most at risk?

a client 86 years of age who is bedfast Explanation: Most pressure injuries occur in adults older than 65 years as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation due to the inability to move around and fecal and urinary incontinence while in the bed.

Which type of wound drainage should alert the nurse to the possibility of infection?

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. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection.

What intervention should be included in a plan of care to prevent pressure injury development in health care settings?

implementing an every-2-hours turning schedule Explanation: To protect clients at risk for the adverse effects of pressure, implement turning on an every-2-hours schedule in the health care setting. More frequent position changes may be necessary, depending on the client. Never use ring cushions or "doughnuts." A pressure-relieving support surface can be expensive; using a 2-hour turn schedule is cost-effective.

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should the nurse prioritize in order to minimize the client's chance of skin breakdown?

repositioning the client on a regular basis Explanation: It is imperative to regularly turn and reposition the client who is immobile in order to prevent ischemia and consequent skin breakdown. Hydration is also necessary to maintain skin integrity, but dehydration is less of a risk factor than is prolonged immobility. It is unnecessary to keep the client upright, such as in the semi-Fowler or high Fowler position, in order to protect the skin. Massage may promote circulation, but it is less important than turning the client on a scheduled basis.

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar. Explanation: The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is calledeschar. Eschar is a thick, leathery scab or dry crust that is necrotic

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

"I respect your wish not to look at it right now." Explanation: The sight of the wound may disturb a client. If the wound involves a change in normal body functions or appearance, the client may not want to look at the wound. With patience and emotional support, clients learn to cope with and adapt to their wounds in time. Telling the client that he or she will not be able to go home, that the wound doesn't look bad, and "You are going to have to look at it someday" are not caring statements expected of a nurse.

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage. Explanation: After completing a dressing change and retuning the client to a comfortable position, it is important to document color, odor, amount, and the type of wound drainage. Early documentation helps to assure the most accurate information can be recorded. Determining the extent of wound undermining and measuring length, width, and depth of the wound should be performed during the dressing change, while the wound is still exposed. The healthy tissue surrounding the wound should never be massaged because it could cause further breakdown of healthy tissue.

The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, the nurse will incorporate which nursing measure?

Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. Explanation: The nurse should plan to administer a prescribed analgesic 30 to 45 minutes prior to changing the dressing. Analgesic administration immediately prior to a dressing change will not allow the analgesic to reach its maximum pain control impact. When clients are fatigued, the sensation of pain may be greater. Also, plan to change the dressing midway between meals so that the client's appetite and mealtimes are not disturbed.

Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues.

True Explanation: True: Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues.

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

decubitus ulcer Explanation: Many factors predispose an individual to pressure injuries; factors can be physical (local infections, malnutrition), functional (impaired mobility, incontinence), or psychosocial (poor adherence to treatment, impaired cognition).

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?

infection Explanation: Symptoms of infection usually become apparent within 2 to 7 days after an injury or surgery; often the client is at home. Symptoms include purulent drainage; increased drainage; pain, redness, and swelling around the wound; increased body temperature; and increased WBCs.

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?

nonblanchable redness Explanation: A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. A stage II pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer. A stage III pressure injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. A stage IV pressure injury involves 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 includes undermining and tunneling.