PrepU Ch 32

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." "Dehiscence is not anything that you need to worry about." "Dehiscence is a total separation of the wound with protrusion of the viscera through it." "Dehiscence is the softening of tissue due to excessive moisture."

"Dehiscence is when a wound has partial or total separation of the wound layers."

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

Dehiscence of the wound

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 bulb-like system will stay in place permanently after your mastectomy." "You will receive medication through this device." "Drainage will occur by gravity and capillary action."

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

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? An individual's skin changes little over the life span. An infant's skin and mucous membranes are easily injured and at risk for infection. A child's skin becomes less resistant to injury and infection as the child grows. 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.

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them? Notify the health care provider of the dried blood and wait for a prescription to proceed. Apply a warm compress to the surgical staples and allow the dried blood to melt. Apply moist saline compresses to loosen crusts before attempting to remove the staples. Go ahead and remove the staples as they will pop up and out of the skin.

Apply moist saline compresses to loosen crusts before attempting to remove the staples.

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? Superficial contusion accompanied by pruritus Superficial abscess accompanied by pruritus Diffuse fungal infection accompanied by pruritus Diffuse dermatitis accompanied by pruritus

Diffuse dermatitis accompanied by pruritus

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 best action by the nurse at this time? Gently rub and massage the area to warm it up. Document the findings in the client's medical record. Notify the health care provider of the findings. Discontinue the therapy and assess the client.

Discontinue the therapy and assess the client.

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 Frequently orient client to place and situation Perform passive range-of-motion exercises

Implement a 2-hour repositioning schedule

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 I Stage IV Stage III Stage II

Stage II

A client receiving a sitz bath starts complaining of light-headedness to the nurse. What is the nurse's most appropriate action? Reassure this is a normal effect and monitor the client closely. 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 and call for help

Stop the sitz bath and call for help

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? Maintains a moist environment Supports the area around the wound Reduces swelling and inflammation Keeps the wound clean

Supports the area around the wound

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Black classification Unstageable Yellow classification Red classification

Unstageable

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

an obese woman with a history of type 1 diabetes

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

foul-smelling drainage that is grayish in color

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

The nurse has obtained a client's capillary blood glucose sample and the results are significantly lower than reference range. What is the nurse's priority action? Obtain a full set of vital signs. Assess the client for signs and symptoms of hypoglycemia. Obtain a sample from the opposite hand for comparison. Promptly inform the primary care provider.

Assess the client for signs and symptoms of hypoglycemia.

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? Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. Rotate the swab several times over the wound surface to obtain an adequate specimen.

Rotate the swab several times over the wound surface to obtain an adequate specimen.

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

a surgical incision with sutured approximated edges

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? hydrocolloid transparent film alginate hydrogel

hydrocolloid

When a client provides a return demonstration of appropriate food selections for carbohydrates, which food does the nurse acknowledge as rich in carbohydrates? Select all that apply. chicken beef milk oatmeal bread

milk oatmeal bread

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 gauze transparent bandage

transparent