Prep U Chapter 32: Skin Integrity and Wound Care

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? A superficial partial-thickness burn, which can appear dry and leathery Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown May vary from brown or black to cherry red or pearly white; bullae may be present Superficial, which may be pinkish or red with no blistering

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

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "Have you had any recent illnesses?" "Do you use any lotions on your skin?" "Do you experience incontinence?" "How many meals a day do you eat?"

"Do you experience incontinence?"

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

"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? "You will receive medication through this device." "This drain minimizes the chance for bacteria to enter the surgical site." "It provides a way to remove drainage and blood from the surgical wound." "The bulb-like system will stay in place permanently after your mastectomy."

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

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? "Reinforced adhesive skin closures will hold my wound together until it heals." "After delivery, I will have sutures in place." "I may have staples in place for a number of days." "I will not remove the staples myself."

"Reinforced adhesive skin closures will hold my wound together until it heals."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? "The margins of your wound are not in direct contact." "Very little scar tissue will form." "The surgeon will leave your wound open intentionally for a period of time." "This is a complex reparative process."

"Very little scar tissue will form.

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

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? Infection of the wound Evisceration of the viscera Dehiscence of the wound Herniation of the wound

Dehiscence of the wound

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? The heart must be able to pump adequately. The volume of circulating blood must be sufficient. Local capillary pressure must be lower than external pressure. Arteries and veins must be patent and functioning well.

Local capillary pressure must be lower than external pressure.

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? Yellow Red Blue-grey White

Red

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? Tearing of the skin and tissue with some type of instrument; tissue not aligned Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of a structure from its normal position Puncture of the skin

Tearing of a structure from its normal position

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? The nurse places the heating pad under the client's neck. The nurse uses a safety pin to attach the pad to the bedding. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. The nurse covers the heating pad with a heavy blanket.

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

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? an older client with arthritis a client with cardiovascular disease a newborn a critical care client

a critical care client

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

a surgical incision with sutured approximated edges

The nurse is using the Braden Scale to determine a client's risk for pressure injuries. What criteria will the nurse assess? Select all that apply. ability friction sensory perception nutrition age

ability friction sensory perception nutrition

The nurse would recognize which client as being particularly susceptible to impaired wound healing? an obese woman with a history of type 1 diabetes A client who is NPO (nothing by mouth) following bowel surgery a man with a sedentary lifestyle and a long history of cigarette smoking a client whose breast reconstruction surgery required numerous incisions

an obese woman with a history of type 1 diabetes

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? elevating and supporting the stump exerting equal, but not excessive, tension with each turn of the bandage wrapping distally to proximally keeping the bandage free of gaps between turn

elevating and supporting the stump

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 fourth degree or fat layer first degree or superficial third degree or full thickness

second degree or partial thickness

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother: to apply sunscreen when exposed to ultraviolet rays. that lanugo is hair of a different color that is permanent. to never trim the baby's nails due to susceptibility to infection. to only use cloth diapers, since disposable ones can cause eczema.

to apply sunscreen when exposed to ultraviolet rays.

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

"Your wound will heal slowly as granulation tissue forms and fills the wound."

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? laxatives potassium supplements corticosteroids antihypertensive drugs

corticosteroids

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown? Massage skin surfaces daily, especially areas under pressure and bony prominences Implement a 2-hour repositioning schedule Perform passive range-of-motion exercises Frequently orient client to place and situation

Implement a 2-hour repositioning schedule

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action? Reassure the client that this is a normal effect of a sitz bath and monitor the client closely. Stop the sitz bath, call for help, and help the client to the toilet to sit down. Call a code blue because the client may be experiencing a myocardial infarction. Stop the sitz bath and help the client ambulate back to the client room.

Stop the sitz bath, call for help, and help the client to the toilet to sit down.

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? Scarring, sutures, and wound care Tetanus, being able to walk, and scarring Prevention of recurring infection, ability to work, and wound care Tetanus, infection, wound care, and pain control

Tetanus, infection, wound care, and pain control

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True False

True

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply. covering the wound with a gauze moistened with normal saline using sterile technique packing the wound with iodoform gauze reinserting the protruding structures and applying a pressure dressing placing the client in the low Fowler position

covering the wound with a gauze moistened with normal saline using sterile technique placing the client in the low Fowler position

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

dehiscence.

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 provide incontinent care every 4 hours as needed elevate the head of the bed 90 degrees place a foot board on the bed

use pillows to maintain a side-lying position as needed

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? "Necrotic tissue is devitalized tissue that must be removed to promote healing." "That is called slough, and it will usually fall off." "You are seeing undermining, a type of tissue erosion." "This is normal tissue."

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

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 called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing." "This is normal tissue." "That is old clotted blood underneath the wound"

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

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? In children younger than 2 years, the skin is thicker and stronger than in adults. An infant's skin and mucous membranes are easily injured and at risk for infection. An individual's skin changes little over the life span. A child's skin becomes less resistant to injury and infection as the child grows.

An infant's skin and mucous membranes are easily injured and at risk for infection.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: lanugo. milia. prickly heat. acne vulgaris.

milia.

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? serous sanguineous serosanguineous purulent

serosanguineous

Which is not considered a skin appendage? Eccrine sweat glands Hair Connective tissue Sebaceous gland

Connective tissue

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? Pasta salad Green beans Banana Fish

Fish

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? Stop removing staples and apply an abdominal pad over the incision. Apply an occlusive pressure dressing after removing the staples. Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple is removed.

Stop removing staples and inform the surgeon

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse uses wet-to-dry dressings continuously. The nurse packs the wound cavity tightly with dressing material. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown.

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

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 sterile tongue blade lubricated with water soluble gel an otic curette a sterile, flexible applicator moistened with saline a small plastic ruler

a sterile, flexible applicator moistened with saline

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? hemorrhage dehiscence fistula evisceration

evisceration

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? hydrocolloid dressing alginate transparent film hydrogel

hydrocolloid dressing

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? small amount of drainage that appears to be mostly fresh blood foul-smelling drainage that is grayish in color large amounts of drainage that is clear and watery and has no smell copious drainage that is blood-tinged

foul-smelling drainage that is grayish in color

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." "This procedure can be safely preformed using clean technique if care is taken not to touch the wound." "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

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

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 If there is contamination of dirt and debris Staging the wound for assessment The event leading up to the trauma

The status of the client's tetanus immunization

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 purulent drainage from the wound bed in order to accurately assess it removing excess drainage and wet tissue to prevent maceration of surrounding skin stimulating the wound bed to promote the growth of granulation tissue removing dead or infected tissue to promote wound healing

removing dead or infected tissue to promote wound healing

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? hydrocolloid transparent bandage gauze

transparent