PNU 120 Taylor PrepU Chapter 32 Skin Integrity and Wound Care
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."
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?
"Do you experience incontinence?"
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 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.
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
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?
Rotate the swab several times over the wound surface to obtain an adequate specimen.
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
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?
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
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
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.
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
The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:
second degree or partial thickness
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?
serosanguineous
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?
transparent
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
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?
"I will put a layer of cloth between my skin and the ice pack."
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 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?
"That is necrotic tissue, which must be removed to promote healing."
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
"Very little scar tissue will form."
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?
An infant's skin and mucous membranes are easily injured and at risk for infection.
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?
Assess the client's wound and vital signs.
What should the nurse assess before application of sitz bath therapy? Select all that apply.
Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void
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
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?
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 stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order.
Hemostasis Inflammatory Proliferation Maturation
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.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is mostappropriate?
Reduce the time interval between dressing changes.
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?
Stage II
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?
Subcutaneous tissue
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.
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 works outward from the wound in lines parallel to it.
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
The nurse would recognize which client as being particularly susceptible to impaired wound healing?
an obese woman with a history of type 1 diabetes
Which is not considered a skin appendage?
connective tissue
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?
contusion
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 client with the history of systemic lupus erythematosus underwent a surgical repair of a right inguinal hernia. The client now presents to the emergency department with the report that the incision appears to have opened. Which action should the nurse prioritize after performing the focused assessment?
question the use of prednisone
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 documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?
serosanguineous