Prep U for chapter 31 wound care
The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment?
"Do not douche 24-48 hours before the procedure."
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 about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?
"Steri-Strips 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?
"Very little scar tissue will form."
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.
"Your wound edges are right next to each other." "Very little scar tissue will form." "This is a simple reparative process."
A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure?
Clean the wound from the top to the bottom, and center to outside.
The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse to select to promote wound healing?
Fish
The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?
Gauze
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which of the following actions should the nurse perform in obtaining a wound culture?
Keep the swab and inside of the culture tube sterile
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? Arteries and veins must be patent and functioning well The heart must be able to pump adequately Local capillary pressure must be lower than external pressure The volume of circulating blood must be sufficient
Local capillary pressure must be lower than external pressure
A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?
Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.
The nurse is instructing mothers of toddlers on the care of skin and the prevention of injury. The nurse should include which of the following educational interventions?
Protect from burns by covering electric outlets, and have a safe zone.
A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?
Supports the area around the wound
A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound?
Suspected deep tissue injury
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.
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 ulcer?
Use pillows to maintain a side-lying position as needed.
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 considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces?
a client sitting in a chair who slides down
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
A skin infection caused by beta-hemolytic streptococci common in children is:
impetigo