NURS 3111 Exam 3 Ch 32

a) Preventing the client from sliding in bed Pg. 1055 Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue.

1. Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? a) Preventing the client from sliding in bed b) Improving the client's hydration c) Pulling the client up from under the arms d) Lubricating the area with skin oil

b) Hydrocolloid Pg. 1073 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.

10. 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) Hydrogel b) Hydrocolloid c) Alginate d) Transparent film

a) Removing dead or infected tissue to promote wound healing Pg. 1054 Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

11. 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? a) Removing dead or infected tissue to promote wound healing b) Stimulating the wound bed to promote the growth of granulation tissue c) Removing excess drainage and wet tissue to prevent maceration of surrounding skin d) Removing purulent drainage from the wound bed in order to accurately assess it

c) A sterile, flexible applicator moistened with saline Pg. 1107 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.

12. 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) An otic curette b) A sterile tongue blade lubricated with water soluble gel c) A sterile, flexible applicator moistened with saline d) A small plastic ruler

d) Clean the wound from the top to the bottom and from the center to outside Pg. 1096-1100 Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.

13. A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? a) Once the wound is cleaned, gently dry the wound bed with an absorbent cloth b) Use clean technique to clean the wound c) Clean the wound in a circular pattern, beginning on the perimeter of the wound d) Clean the wound from the top to the bottom and from the center to outside

a) Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures Pg. 1082 If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

14. 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? a) Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures b) Carefully pick the crusts off the sutures with the forceps before removing them c) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them d) Do not attempt to remove the sutures because the wound needs more time to heal

d) Cleanse with a new gauze for each stroke Pg. 1098 When cleansing a wound, the nurse should use a new gauze or swab on each downward stroke of the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside.

15. A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care? a) Cleanse the wound in parallel strokes from the top to the bottom of the wound b) Cleanse the wound from the outer area toward the inner area c) Cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing d) Cleanse with a new gauze for each stroke

b) "This is a simple reparative process" c) "Your wound edges are right next to each other" d) "Very little scar tissue will form" Pg. 1048 Very little scar tissue is expected to form during first-intention healing in a wound whose wound edges are close to each other. 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.

16. The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. a) "Your wound will be purposely left open for a time" b) "This is a simple reparative process" c) "Your wound edges are right next to each other" d) "Very little scar tissue will form" e) "The margins of your wound are widely separated"

b) As a stage I pressure injury Pg. 1054 Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV.

17. 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? a) As a stage II pressure injury b) As a stage I pressure injury c) As a stage III pressure injury d) As a stage IV pressure injury

d) "It provides a way to remove drainage and blood from the surgical wound" Pg. 1080 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.

18. 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) "The bulb-like system will stay in place permanently after your mastectomy" d) "It provides a way to remove drainage and blood from the surgical wound"

a) Desiccation Pg. 1050 Desiccation is localized wound dehydration. Maceration is localized wound overhydration 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.

19. 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? a) Desiccation b) Necrosis c) Evisceration d) Maceration

a) "Your wound will heal slowly as granulation tissue forms and fills the wound" Pg. 1084 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.

2. 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) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention" c) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal" d) "As soon as the infection clears, your surgeon will staple the wound closed"

d) To provide drainage for bile Pg. 1064 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.

20. 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 divert drainage to the peritoneal cavity c) To decrease dead space by decreasing drainage d) To provide drainage for bile

c) "Do you experience incontinence?" Pg. 1054 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.

21. 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 use any lotions on your skin?" b) "Have you had any recent illnesses?" c) "Do you experience incontinence?" d) "How many meals a day do you eat?"

b) Apply saline solution-moistened gauze over the protruding area Pg. 1075 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.

22. 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) Inform the client that this is an expected occurrence and not to worry b) Apply saline solution-moistened gauze over the protruding area c) Allow the wound and intestinal contents to remain open to air d) Pack the wound with gauze pads and a dry sterile dressing

c) A surgical incision with sutured approximated edges Pg. 1048 Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.

3. The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a) A large wound with considerable tissue loss allowed to heal naturally b) A wound left open for several days to allow edema to subside c) A surgical incision with sutured approximated edges d) A wound healing naturally that becomes infected

d) Applying sterile dressings with normal saline over the protruding organs and tissue Pg. 1053 The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

4. A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? a) Assessing for impaired blood flow to the area of evisceration b) Monitoring for pallor and mottled appearance of the wound c) Contacting the surgeon d) Applying sterile dressings with normal saline over the protruding organs and tissue

a) "I will put a layer of cloth between my skin and the ice pack" Pg. 1087 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.

5. 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 will put a layer of cloth between my skin and the ice pack" b) "I must wait 15 minutes between applications of cold therapy" c) "I can let this stay on my ankle an hour at a time" d) "I should keep this on my ankle until it is numb"

c) Rotate the swab several times over the wound surface to obtain an adequate specimen Pg. 1112-1115 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.

6. 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) Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain b) Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station 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

a) Assess the client's wound and vital signs Pg. 1116-1121 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.

7. 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) Document the pain and vital signs c) Notify the health care provider of the pain d) Administer the prescribed analgesic

a) The status of the client's tetanus immunization Pg. 1048 Staging the wound is only done with pressure injuries. The presence of dirt or debris is something that will need to be addressed, but not the most important assessment. Understanding how the client stepped on the nail will need to be noted and is a possible educational opportunity for prevention, but it is not the most important assessment concern. Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defense against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.

8. 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? a) The status of the client's tetanus immunization b) Staging the wound for assessment c) The event leading up to the trauma d) If there is contamination of dirt and debris

c) Diffuse dermatitis accompanied by pruritus Pg. 1047 The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching. A contusion is a closed wound with bleeding in underlying tissues from a blunt blow. Fungal infections do not cause a rash or itching. An abscess is a localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed.

9. 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? a) Superficial abscess accompanied by pruritus b) Superficial contusion accompanied by pruritus c) Diffuse dermatitis accompanied by pruritus d) Diffuse fungal infection accompanied by pruritus