PrepU ch.32 skin integrity and wound care

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? a.White b.Red c.Blue-grey d.Yellow

b. Red Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1053

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy. Which interventions should the nurse follow to apply the T-binder? (Select all that apply.) -Fasten the crossbar around the waist. -Pass the tails through the client's legs. -Clean the insertion in a circular manner. -Pin the tails to the belt of the T-binder. -Place the precut drain sponge on the anus.

-Fasten the crossbar around the waist. -Pass the tails through the client's legs. -Pin the tails to the belt of the T-binder. When applying a T-binder to secure a dressing to the anus of a client who has undergone hemorrhoidectomy for piles, the nurse fastens the crossbar of the T around the waist. Then the nurse passes the single or double tails between the client's legs and pins the tails to the belt. Adhesive sanitary napkins worn inside briefs are an alternative to a T-binder for stabilizing absorbent materials. When managing a closed drain, the nurse cleans the insertion in a circular manner. After cleansing, the nurse places a precut drain sponge or gauze, which is open to its center, around the base of the drain. Chapter 32: Skin Integrity and Wound Care - Page 1077

Which client(s) is considered at risk for skin alterations? Select all that apply. -an adolescent with multiple body piercings -a client in a monogamous same-sex relationship -a client receiving radiation therapy -a client undergoing cardiac monitoring -a client with diabetes

-an adolescent with multiple body piercings -a client receiving radiation therapy -a client with diabetes Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a sexual relationship with multiple gay male partners would also place a client at risk for HIV and skin alterations, but this client is in a monogamous relationship. Cardiac monitoring does not place a client at risk for skin alterations. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1046

What intervention(s) should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply. -proper client nutrition -2-hour turn schedule -pressure redistribution support surfaces -head of bed positioned at 45 degrees -pillow placed under knees -client repositioning with a lift

-proper client nutrition -2-hour turn schedule -pressure redistribution support surfaces -client repositioning with a lift To protect clients at risk for the adverse effects of pressure, the nurse will implement turning on an every-2-hours schedule in the health care setting. More frequent position changes may be necessary, depending on the client. Use of a pressure redistribution support surface can be expensive, but it is an effective way to prevent a pressure injury. The nurse will also keep heels from pressing on the bed for immobile clients and advise against prolonged sitting. While sitting or lying, the client will use positioning devices or pillows to keep boney prominences from rubbing on each other or pressing onto a surface. Placing pillows under the knees while supine puts pressure on the heels against the mattress. The nurse will protect the client's skin from friction and shear by lifting the client when moving or repositioning and keep the head of bed at 30 degrees or less. Positioning at client on a bed while the head of the bed is at a 45 degree angle could cause the client to have a skin shear or friction injury. The nurse will provide adequate calories and nutrients. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1093 - 1094

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.Diffuse dermatitis accompanied by pruritus b.Superficial contusion accompanied by pruritus c.Diffuse fungal infection accompanied by pruritus d.Superficial abscess accompanied by pruritus

a. Diffuse dermatitis accompanied by pruritus 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1047

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client? a.Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs b.Placing the client in the supine position with a pillow under the knees c.Placing the client in a side-lying position with a pillow between the lower legs d.Placing the client in a wheelchair with the back of the feet resting against the heel loops

a. Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues. Pressure points in bed vary depending on the size and shape of client and the position. Pressure points while sitting in a chair or wheelchair also vary depending of the style, shape, and construction of the chair or wheelchair, the clients position in the chair, and the size and shape of the client. Any boney prominence or areas under a large amount of pressure against a hard or semihard surface can create a pressure injury. To protect clients at risk for pressure injury, the nurse implements a 2-hour turn schedule, uses a pressure redistribution support surface, keeps pressure points from pressing on the bed or chair by using positioning devices or pillows, keeps boney prominences from rubbing on each other, minimizes exposure of skin to incontinence, perspiration, or wound drainage, and provides adequate calories and nutrients. A pillow placed between the lower legs in side-lying position will prevent ankle to ankle pressure, but not ankle to mattress pressure. Placing a pillow under the knees while positioned supine will increase pressure on the heels. While using a wheelchair, it is best to have the client wear well-fitted shoes and position the feet on the footplate and remove the heel rest or heel loop. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1149

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? a.To splint the area when engaging in activity b.To ambulate using a cane or walker c.To remain in bed for the next 4 hours d.To turn the head away from the area whenever coughing

a. To splint the area when engaging in activity To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection. Chapter 32: Skin Integrity and Wound Care - Page 1082

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

a. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery. Chapter 32: Skin Integrity and Wound Care - Page 1073

A client's risk for the development of a pressure injury is most likely due to which lab result? a.albumin 2.5 mg/dL b.glucose 110 mg/dL c.hemoglobin A1C 7% d.sodium 135 mEq/L

a. albumin 2.5 mg/dL An albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury. A hemoglobin A1C level greater than 8% puts the client at risk for the development of pressure injuries due to a prolonged high glucose level. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not put the client at risk for the development of a pressure injuries. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1066

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? a."The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." b."The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." c."The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." d."This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."

b. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present. Chapter 32: Skin Integrity and Wound Care - Page 1064

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? a.Notify the surgeon STAT b.Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement c.Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon d.Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

b. Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration. Approximating the wound edges and applying wound closure tapes may cause the client undue pain and trap bacteria in the wound. Irrigating the open wound may cause unwanted bacteria from the surrounding area to wash into the wound. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1096

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? a.Infection of the wound b.Herniation of the wound c.Dehiscence of the wound d.Evisceration of the viscera

c. Dehiscence of the wound Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents. Chapter 32: Skin Integrity and Wound Care - Page 1053

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? a.Epidermis b.Dermis c.Subcutaneous tissue d.Muscle layer

c. Subcutaneous tissue The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1044

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

c. dehiscence Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents. Chapter 32: Skin Integrity and Wound Care - Page 1053

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound? a.hemostasis b.inflammatory phase c.proliferation phase d.maturation phase

c. proliferation phase The wound description reveals a beefy red wound bed that bleeds easily. This is the proliferation stage and describes granulation tissue. Hemostasis is the initial phase, involving activation of platelets. In the inflammatory phase, white blood cells and macrophages enter the wound to remove debris. The maturation phase involves collagen remodeling and scar formation. Chapter 32: Skin Integrity and Wound Care - Page 1050

Which best describes the proliferative phase, the third phase of the wound healing process? a.the onset of vasoconstriction, platelet aggregation, and clot formation b.marked by vasodilation and phagocytosis as the body works to clean the wound c.reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization d.decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound

c. reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing, hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

The registered nurse (RN) observes the licensed practical nurse (LPN) performing this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? (photo shows nurse with gloves applying gel to the incision with gloved fingers) a."Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." b."This procedure can be safely performed using clean technique if care is taken not to touch the wound." c."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)." d."To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

d. "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside. Chapter 32: Skin Integrity and Wound Care - Page 1099

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 most appropriate? a.Reduce the time interval between dressing changes. b.Assure that the packing material is completely saturated when placed in the wound. c.Use less packing material. d.Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.

d. Reduce the time interval between dressing changes. Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1096-1101

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. 1-Maturation 2-Hemostasis 3-Inflammatory 4-Proliferation

-Hemostasis -Inflammatory -Proliferation -Maturation The correct order of the phases of wound healing is hemostasis, inflammatory, proliferation, and maturation. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1049-1050

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

c. Stop the sitz bath, call for help, and help the client to the toilet to sit down. If the client complains of feeling light-headed or dizzy during a sitz bath: Stop the sitz bath. Do not attempt to ambulate the client alone. Use call light to summon help. Let the client sit on the toilet until feeling subsides or help has arrived to assist the client back to bed. This does not necessarily warrant a code blue unless the nurse suspects an acute onset of a serious health problem. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1088

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

b. to provide drainage for bile. 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1064

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

a. corticosteroids Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1052

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.Maceration c.Necrosis d.Evisceration

b. Desiccation 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. Chapter 32: Skin Integrity and Wound Care - Page 1050

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? a.gauze b.adhesive strips with eyelets c.transparent d.hydrocolloid

c. transparent Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1073

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound? a.There is an infection present. b.The client has wound dehiscence. c.There is evidence of evisceration. d.The client has fistula formation.

d. The client has fistula formation. A fistula is an abnormal tubelike passageway that forms from one organ to outside the body. There is no information that would lead to a suspicion that the wound is infected. Wound dehiscence would be indicated by separation of the wound and evisceration would be evidenced by protrusion of abdominal contents through the wound. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1053

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? a.Gentle cleansing b.Wound irrigation c.Debridement d.Apply moist dressing

b. Wound irrigation With the yellow classification using the RYB wound classification system, wound irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

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

a. Stop removing staples and inform the surgeon If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence. Chapter 32: Skin Integrity and Wound Care - Page 1082

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

b. applying sterile dressings with normal saline over the protruding organs and tissue 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. Chapter 32: Skin Integrity and Wound Care - Page 1053

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply. -Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. -Change the dressing midway between meals. -Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. -Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. -Apply an absorbent dressing material as the first layer of the dressing. -Apply a nonabsorbent material over the first layer of absorbent material.

-Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. -Change the dressing midway between meals. -Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. The nurse would administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. The medication would be in the client's system at the time of the dressing change. The nurse would change the dressing midway between meals so that pain and discomfort would be at a minimum at the time of the meal. A protective paste or ointment would protect the surrounding skin from the drainage of the wound. There is no need to apply another layer of protective ointment or paste on top of the previous layer when changing dressings. The nurse would not apply an absorbent dressing material as the first layer of the dressing. The nurse wants to wick the drainage from the wound. The nurse would not apply a nonabsorbent material over the first layer of absorbent material. Again, the nurse wants to wick the drainage from the wound. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

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

c. Rotate the swab several times over the wound surface to obtain an adequate specimen. 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. Chapter 32: Skin Integrity and Wound Care - Page 1112-1115

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. -Draw the shape of the wound with a description. -Measure the wound's length and width. -Use a dry sterile applicator at a 90-degree angle to measure depth. -Chart tunneling by using a quadrant approach to describe the location. -Assess color, drainage, presence of pain, or complications.

-Draw the shape of the wound with a description. -Measure the wound's length and width. -Assess color, drainage, presence of pain, or complications. When charting the findings, draw an irregular-shaped wound, as in this question, and provide a description including its length and width. A sterile applicator moistened with saline should be used to measure the depth of a wound and to determine the presence of tunneling. A dry applicator could damage the wound by sticking to it. The nurse would use the imaginary face of a clock when describing where on the wound the locations of tunneling exist. The nurse would assess the color of the wound, and presence of drainage, pain or discomfort, and any complications, and include these in the charting. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1062

A nurse is providing wound care for a client who has a pressure injury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options. 1-Use nonsterile gloves. 2-Apply sterile gloves. 3-Cleanse the wound with normal saline. 4-Remove old dressing. 5-Apply wound covering. 6-Give pain medication.

1-Give pain medication. 2-Use nonsterile gloves. 3-Remove old dressing. 4-Apply sterile gloves. 5-Cleanse the wound with normal saline. 6-Apply wound covering. The correct order for this dressing change is giving pain medication, applying nonsterile gloves to remove old dressing, removing old dressing, applying sterile gloves, cleansing the wound with normal saline, and applying a wound covering. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1092

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? a.elevate the head of the bed 90 degrees b.use pillows to maintain a side-lying position as needed c.provide incontinent care every 4 hours as needed d.place a foot board on the bed

Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury. Chapter 32: Skin Integrity and Wound Care - Page 1091

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

a. "Do you experience incontinence?" 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1054

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? a.A Penrose drain promotes passive drainage into a dressing. b.A Penrose drain is a closed drainage system that is connected to an electronic suction device. c.A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. d.A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

a. A Penrose drain promotes passive drainage into a dressing. A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure. Chapter 32: Skin Integrity and Wound Care - Page 1079

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? a.Apply a skin protectant to the skin around the incision. b.Apply a skin protectant to the incision site. c.Apply a sterile gauze sponge over the incision site. d.Apply a transparent dressing over the incision site.

a. Apply a skin protectant to the skin around the incision. Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied. Chapter 32: Skin Integrity and Wound Care - Page 1082

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making? a.The nurse should apply adhesive wound closure strips after removing staples. b.The nurse should thoroughly irrigate the wound 15 to 30 minutes before the procedure. c.The nurse may delegate this task to unlicensed assistive personnel (UAP). d.The nurse should remove the staples in sequence, beginning at the proximal edge of the wound.

a. The nurse should apply adhesive wound closure strips after removing staples. After skin staples are removed, adhesive wound closure strips are applied across the wound to keep the skin edges approximated as the wound continues to heal. This task cannot be delegated to UAP. Irrigation is not necessary and alternating staples should be removed to prevent dehiscence. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1082

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

c. Clean the wound from the top to the bottom and from the center to outside. 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1096-1100

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? a.serous b.sanguineous c.serosanguineous d.purulent

c. serosanguineous Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink or pink-yellow. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection. Chapter 32: Skin Integrity and Wound Care - Page 1063

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? a."Be sure to take at least two showers daily to remove all microorganisms from the skin." b."Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." c."Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." d."Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

d. "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue. As such, clients should be taught to avoid soaps with artificial ingredients or fragrances, as these may be harsher on the skin. It is good to be clean; however, advice of taking at least two showers per day is excessive and may dry the skin. Moisturizer should be applied to the skin following bathing to prevent dryness of the skin. Drinking water is important to remain hydrated; however, the nurse should recommend drinking 1,500 to 2,000 mL of water daily. Drinking 8 ounces three times a day is 720 mL. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1047

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? a.fistula b.dehiscence c.hemorrhage d.evisceration

d. evisceration Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude. Chapter 32: Skin Integrity and Wound Care - Page 1053

The nurse is preparing to irrigate a client's abdominal wound following wound dehiscence. Arrange the presented nursing activities in the correct order. Use all options. 1-Discuss the procedure with the client and assess client knowledge. 2-Gather equipment required for a dressing change. 3-Drape the client to expose the area of the wound. 4-Position the client to facilitate filling the wound cavity with solution 5-Open and prepare supplies following the principles of surgical asepsis. 6-Don gloves and other personal protective equipment. 7-Fill the syringe with solution, and instill it into the wound. 8-Dry the skin surrounding the wound.

1-Discuss the procedure with the client and assess client knowledge. 2-Gather equipment required for a dressing change. 3-Drape the client to expose the area of the wound. 4-Position the client to facilitate filling the wound cavity with solution 5-Open and prepare supplies following the principles of surgical asepsis. 6-Don gloves and other personal protective equipment. 7-Fill the syringe with solution, and instill it into the wound. 8-Dry the skin surrounding the wound. Nursing activities involved in the process of irrigating a an abdominal wound are to be carried out carefully in the correct sequence to prevent infection of the wound or cause further complications. In order to ensure safe irrigation of the dehisced wound and take all needed steps to ensure infection prevention, the nurse will first check that the client understands the procedure and consents to the nurse carrying out the activity at the scheduled time. This first step also allows the nurse to assess the client's pain level and take measures to manage pain prior to commencing irrigation. Because the nurse will introduce moisture to the wound by irrigating it, a dressing change will be needed. The nurse will be prepared for this by gathering supplies after the intervention has first been discussed with the client. The nurse will then position the client comfortably and drape the client exposing only the wound. The client's comfort is increased if privacy is protected. The nurse can now reposition the client to ensure the irrigated solution will drain away from the wound to prevent infection. The nurse will then open and prepare supplies following the principles of surgical asepsis, followed by donning gloves and personal protective equipment. Finally, the nurse will fill the syringe with solution, and instill it into the wound and be sure to dry the skin surrounding the wound to reduce moisture and the risk of infection as well as to create skin conditions that are conducive to effectively applying a new dressing. Chapter 32: Skin Integrity and Wound Care - Page 1092

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client? a.Monitor intake and output. b.Assess the coccyx area for blanching. c.Monitor the client for nausea. d.Assess mental status.

a. Monitor intake and output. A client with diarrhea caused by Clostridium difficile is at risk for dehydration. As such, the priority assessments should include intake and output, skin turgor, condition of mucous membranes, and vital signs. Assessing the coccyx area for blanching should be done with shift assessments; however, circulating fluid volume takes priority. Monitoring for nausea and assessing the client's mentation is not directly related to the effects of the infectious diarrhea. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1046

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a.Contact the surgeon for debridement. b.Using sterile technique, debride the wound. c.Off-load pressure from the heel. d.Place an antiembolism stocking on the client's leg.

c. Off-load pressure from the heel. The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. The surgeon does not need to be consulted for a debridement. Utilizing an antiembolism stocking on the client will not impact the status of the heel wound. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? a.primary intention b.maturation c.secondary intention d.tertiary intention

c. secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1075

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? a.a newborn b.a client with cardiovascular disease c.an older client with arthritis d.a critical care client

d. a critical care client Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1054

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? a.stage I b.stage II c.stage III d.stage IV

d. stage IV Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1058

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. -Insert a swab into the wound. -Press and rotate the swab several times over the wound surfaces. -Place the swab in the culture tube when done. -Use the same swab for both wound sites. -Touch the swab to the intact skin at the wound edges. -Tap the outside of the culture tube with the swab before placing it in the tube.

-Insert a swab into the wound. -Press and rotate the swab several times over the wound surfaces. -Place the swab in the culture tube when done. The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1112-1116

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select? a.Hydrocolloid b.Wet to dry c.Negative wound pressure therapy d.Telfa

a. Hydrocolloid The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement. Telfa pads are nonstick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1101

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

c. Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture. Chapter 32: Skin Integrity and Wound Care - Page 1048

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? a.The nurse elevates the foot of the bed. b.The nurse uses a ring cushion to protect reddened areas from additional pressure. c.The nurse increases the amount of time the head of the bed is elevated. d.The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

d. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Chapter 32: Skin Integrity and Wound Care - Page 1070