NSG 100: Infection and Tissue Integrity

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.

-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.

The inflammation phase lasts about how many days?

3

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:

A rash related to a yeast infection

systemic infection symptoms

Fever, body aches, chills, nausea, vomiting, weakness, headache, mental confusion, drop in person's normal blood pressure

A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumoniae, which is particularly prone to cause infections, also referred to as what?

Pathogenic

Epidermis function

Protects dermis from trauma, chemicals Controls skin permeability, prevents water loss Prevents entry of pathogens Synthesizes vitamin D3 Sensory receptors detect touch, pressure, pain, and temperature Coordinates immune response to pathogens and skin cancers

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

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

After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? Select all that apply.

Used syringes with attached needles and used finger stick lancet

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from:

bacterial infection

subcutaneous tissue function

energy source, insulation, padding

A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn?

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

Dermis function

nourishes epidermis; provides strength; contains glands

Local infection symptoms

redness, swelling, warmth, pain

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 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?

secondary intention

Secondary intention healing

wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring