Module 5 - Fundamentals prep u

Rotate the swab several times over the wound surface to obtain an adequate specimen

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?

The nurse works outward from the wound in lines parallel to it.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

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

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

Impaired Skin Integrity related to open wound

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?

Off-load pressure from the heel.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

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

he 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?

Tearing of a structure from its normal position

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?

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

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

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?

an obese woman with a history of type 1 diabetes

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

"Do you experience incontinence?"

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

connective tissue

Which is not considered a skin appendage?

use pillows to maintain a side-lying position as needed

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?

Black classification

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document?

Wound irrigation

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?

mechanical debridement

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?

milia

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

A client who has a partial-thickness venous ulcer with moderate drainage

For which client would the application of a hydrocolloid dressing be most appropriate?

a client sitting in a chair but slides down

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?

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

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform?

Discontinue the therapy and assess the client.

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 bestaction by the nurse at this time?

a critical care client

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury?

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

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 nurse places a transparent dressing over a central venous access device insertion site. A nurse uses aseptic techniques when changing a dressing. A nurse places a drainage dressing around a drain insertion site. Explanation:

The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply.

To splint the area when engaging in activity

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

hydrocolloid

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?

Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation.

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

Diffuse dermatitis accompanied by pruritus

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?

The client has fistula formation.

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

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

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

Assess the client's wound and vital signs.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

albumin 2.5 mg/dL

A client's risk for the development of a pressure injury is most likely due to which lab result?

emoving dead or infected tissue to promote wound healing

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action

removing dead or infected tissue to promote wound healing

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?

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

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.

Braden scale

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?

serosanguineous

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?

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

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?

foul-smelling drainage that is grayish in color

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?

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

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

Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done.

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.

provide incontinent care every 2 hours and as needed turn the client every 2 hours when the client is in bed encourage the client to take fluids every 2 hours

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply.

Stop removing staples and inform the surgeon

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?

secondary intention

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?

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

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?

Subcutaneous tissue

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 rash related to a yeast infection.

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:

Dehiscence of the wound

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.

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

Apply a skin protectant to the skin around the incision

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

Apply a skin protectant to the skin around the incision.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

Stage II

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?

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

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

evisceration

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?

Increases the risk of infection by contaminating the wound

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?

Document the findings

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

Document the findings.

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

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

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

There should be a cloth barrier around the ice pack for each 20-minute therapy.

The nurse is caring for a client with a knee sprain. What guidelines will the nurse teach the client about using an ice pack at home?

stage IV

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?

"I will put a layer of cloth between my skin and the ice pack."

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?

Monitor intake and output.

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client?

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer.

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

fish

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?

figure-of-eight turn

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

elevating and supporting the stump

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

transparent

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 sterile, flexible applicator moistened with saline

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?

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

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?

corticosteroids

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

an adolescent with multiple body piercings a client receiving radiation therapy a client with diabetes

Which client(s) is considered at risk for skin alterations? Select all that apply.