PrepU Chapter 31 Skin Integrity and Wound Care

The nurse is caring for a client who has a heavy exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound?

An alginate dressing

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 recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention?

Apply sterile dressings with normal saline over the protruding organs and tissue.

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.

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

True

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force

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 best describes the third phase of the wound healing process: proliferative?

epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization

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.

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

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

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."

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

"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 will put a layer of cloth between my skin and the ice pack."

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include?

"It is important to keep your sutured incision clean."

An older adult client is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply.

"It may take you longer to heal than someone younger." "Eat nourishing foods after surgery to promote healing." "Wound healing can take longer if you have been exposed often to the sun." "Monitor your moods after surgery. Depression after surgery is not normal."

The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What is the appropriate nursing response? Select all that apply.

"Medical maggots are sterilized before they are introduced to the wound." "I understand your concern; let's talk further about your thoughts about this treatment." "The choice regarding whether to have or decline this treatment is yours."

The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate?

"Wounds heal better when a moist wound bed is maintained."

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate?

"You will likely experience periods of increased skin outbreaks and periods of remissions."

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."

The health care provider has ordered a cold ice bag to be applied to the wrist of a client with a sprain. The nurse will assure that the cold application is at what temperature before application?

10 - 18.3 degrees C (50-65 degrees F)

The wound care nurse is performing skin assessments for clients at risk for the development of skin alterations. Which clients does the nurse identify as at greatest risk for skin alterations? Select all that apply.

A client with morbid obesity A client with reports of excessive perspiration A client that has a low BMI

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The oncoming nurse receives in report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

Which is not considered a skin appendage?

Connective tissue

Which nutrient will prevent abnormal pigmentation?

Copper

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

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth

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 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 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 7-year-old who suddenly developed difficulty hearing out of the left ear. Which nursing action is appropriate?

Perform a thorough inspection of the ear.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage?

Serosanguineous

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?

Soak in a warm bath for drainage.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and unblanchable. How will the nurse categorize this pressure ulcer?

Stage I

A client has been admitted to the acute care unit after surgery to debride an infected skin ulceration. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?

Tertiary intention

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?

There is an unintentional separation of the wound.

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 preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline

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 has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn?

gauze

A skin infection caused by beta-hemolytic streptococci common in children is:

impetigo

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 nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention

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