PrepU Chapter 32

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. A) Fingers with quick capillary refill B) Cyanosis C) Warm hand D) No finger numbness or tingling E) Decreased radial pulse

A) Fingers with quick capillary refill C) Warm hand D) No finger numbness or tingling Explanation: The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers. Cyanosis, pallor, coolness, numbness, tingling, swelling, or absent or diminished pulse are signs that circulation may be decreased or that nerve function is impaired.

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) place a foot board on the bed D) provide incontinent care every 4 hours as needed

B) use pillows to maintain a side-lying position as needed Explanation: 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.

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

C) corticosteroids Explanation: 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.

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. A) Apply sterile gloves. B) Remove old dressing. C) Use nonsterile gloves. D) Apply wound covering. E) Give pain medication. F) Cleanse the wound with normal saline.

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

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 Penrose drain promotes passive drainage into a dressing. Explanation: 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.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs. Explanation: First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

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?

Off-load pressure from the heel. Explanation: 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.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

cleanse with a new gauze for each stroke Explanation: When cleansing a wound, the nurse should use a new gauze or swab on each downward stroke of the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside.

A full-thickness or third-degree burn develops a leathery covering called a(an): A) eschar. B) static. C) abrasion. D) erythema.

A) eschar. Explanation: The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

The nurse works outward from the wound in lines parallel to it. Explanation: A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.

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

B) "Do you experience incontinence?"

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 incision site. B) Apply a transparent dressing over the incision site. C) Apply a sterile gauze sponge over the incision site. D) Apply a skin protectant to the skin around the incision.

A) Apply a skin protectant to the skin around the incision. Explanation: 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.

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? A) suspected deep tissue injury B) stage III pressure injury C) stage II wound D) unstageable wound

A) suspected deep tissue injury

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply.

Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it. Explanation: Analgesia can be provided before drain care, if necessary. A gauze pad is used to cleanse the outlet after emptying and the drain is secured to the client's gown with a safety pin. Goggles are not normally necessary. The drain does not require 5 to 7 minutes in order to become fully empty.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform?

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. Explanation: Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

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

B) "I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing? A) maturation phase B) hemostasis phase C) proliferation phase D) inflammatory phase

B) hemostasis phase Explanation: Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin with other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and to release growth factors. The proliferation phase is the regenerative phase in which granulation tissue is formed. The maturation phase involves collagen remodeling.

A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? A) tertiary intention B) secondary intention C) primary intention D) desiccation

B) secondary intention

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 II B) stage IV C) stage III D) stage I

B) stage IV Explanation: 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.

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

B) to apply sunscreen when exposed to ultraviolet rays. Explanation: Sunscreen is necessary to protect against damage caused by ultraviolet rays.

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? A) gauze B) transparent C) hydrocolloid D) bandage

B) transparent Explanation: The nurse should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. A hydrocolloid dressing helps keep the wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? A) Contact the health care provider. B) Change the dressing. C) Document the findings. D) Notify the wound care nurse.

C) Document the findings.

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) maturation B) primary intention C) secondary intention D) tertiary intention

C) secondary intention Explanation: 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.

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. A) ability B) nutrition C) sensory perception D) friction E) age

C) sensory perception B) nutrition A) ability D) friction Explanation: Sensory perception, nutrition, ability, and friction are all criteria used in the Braden Scale. Age is not a graded criterion in predicting the risk for pressure injuries.

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

D) "That is necrotic tissue, which must be removed to promote healing." Explanation: Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? A) circular turn B) spiral-reverse turn C) spica turn D) figure-of-eight turn

D) figure-of-eight turn Explanation: A figure-of-eight turn is used for joints like the elbows and knees. The other answers are incorrect.

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? A) serous B) purulent C) sanguineous D) serosanguineous

D) serosanguineous Explanation: This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. Which type of injuries would the nurse be alert? Select all that apply. One, some, or all responses may be correct A) Bruising B) Soft tissue damage C) Abrasions D) Concussion E) Broken left ankle

E) Broken left ankle C) Abrasions B) Soft tissue damage D) Concussion A) Bruising Explanation: Skateboard related injuries that the nurse needs to assess for are a concussion and other brain injuries, broken bones, soft tissue injuries, and skin abrasions, cuts, and bruises. Symptoms of a concussion are dizziness, headaches, visual changes, loss of memory, slowed speech, and sensitivity to noise. An abrasion involves stripping of layers on the skin's surface. Soft tissue injuries include damage to the muscles, tendons, and ligaments. Dehydration can cause headaches and dizziness; however, since the client injured oneself while skateboarding a concussion should be suspected and assessed for. Because the client reported sliding on the sidewalk, the client should also be assessed for skin abrasions.

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen?

Impaired Skin Integrity related to open wound Explanation: Impaired skin integrity best describes the minor laceration. While the other diagnoses, Pain, Knowledge Deficit, and Risk for Infection, are all possible as a result of the laceration, there is no indication in the scenario that they are the case.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?

biosurgical debridement Explanation: In biosurgical debridement, fly larvae are used to clear the wound of necrotic tissue. This is accomplished by an enzyme the larvae releases. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, as in surgical debridement.

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

A) "Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps? A) Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. B) Apply skin barrier only on the right side of the wound over the irritation. C) Apply skin barrier over the area of irritation to prevent further injury. D) Apply skin barrier only on the side of the wound without any irritation.

A) Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. Explanation: The skin barrier should be placed at least 1 in (2.5 cm) away from the area of irritation and should be placed on both sides of the wound. Skin barrier should not be placed over the area of irritation; it should only be placed on skin that is intact. The skin barrier should be applied to both sides of the wound as the Montgomery straps are applied to both sides of the wound on the intact skin surrounding the wound and 1 in (2.5 cm) away from any irritated or nonintact skin.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? A) Assess the client's wound and vital signs. B) Document the pain and vital signs. C) Notify the health care provider of the pain. D) Administer the prescribed analgesic.

A) Assess the client's wound and vital signs. Explanation: First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

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

A) Clean the wound from the top to the bottom and from the center to outside. Explanation: 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

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) Dehiscence of the wound B) Evisceration of the viscera C) Infection of the wound D) Herniation of the wound

A) Dehiscence of the wound Explanation: 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.

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) Telfa C) Negative wound pressure therapy D) Wet to dry

A) Hydrocolloid Explanation: 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.

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

A) Rotate the swab several times over the wound surface to obtain an adequate specimen. Explanation: 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.

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 Explanation: 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.

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? A) Tetanus, infection, wound care, and pain control B) Prevention of recurring infection, ability to work, and wound care C) Scarring, sutures, and wound care D) Tetanus, being able to walk, and scarring

A) Tetanus, infection, wound care, and pain control Explanation: Chances are the client knows that stepping on a nail could lead to a serious complication or illness, even if the client cannot remember or does not know about tetanus or infections. How to care for the wound is usually something clients will want to know before being discharged. The client in this scenario is reporting pain, so pain control will be one of the concerns. It is unlikely that the client will be worried about scarring on the bottom of the foot or sutures due to it being a puncture. The client is still walking, although in pain and with a limp, it would be unlikely the client would be concerned about being able to walk. More than likely, the client has already figured out the injury may not have occurred or would not be as bad had he or she been wearing shoes, so the nurse would not anticipate the need for preventative education.

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 remain in bed for the next 4 hours C) To turn the head away from the area whenever coughing D) To ambulate using a cane or walker

A) To splint the area when engaging in activity Explanation: 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.

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: A) a rash related to a yeast infection. B) a rash related to immobility. C) an allergic reaction to medications. D) an allergic reaction to detergent.

A) a rash related to a yeast infection. Explanation: Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? A) contusion B) avulsion C) puncture D) incision

A) contusion Explanation: A contusion is an injury to soft tissue, so this is what the nurse expects to see on the basis of the teacher's description of the incident. A puncture involves an opening in the skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripping of the surface layers of skin. In an avulsion injury, large areas of skin and underlying tissues have been stripped away.

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? A) preventing the client from sliding in bed B) lubricating the area with skin oil C) pulling the client up from under the arms D) improving the client's hydration

A) preventing the client from sliding in bed Explanation: Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document? A) serosanguineous B) serous C) purulent D) sanguineous

A) serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink. 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.

An older adult client who 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. A) "Wound healing can take longer if you have been exposed often to the sun." B) "It may take you longer to heal than someone younger." C) "Eat nourishing foods after surgery to promote healing." D) "Monitor your moods after surgery. Depression after surgery is not normal." E) "Try to do everything by yourself at home to build your strength back."

B) "It may take you longer to heal than someone younger." C) "Eat nourishing foods after surgery to promote healing." A) "Wound healing can take longer if you have been exposed often to the sun." D) "Monitor your moods after surgery. Depression after surgery is not normal." Explanation: Wound healing can be delayed in older adult clients, especially those with long-term sun exposure. Eating healthy foods can speed healing. A home health aide can assist with caregiving to reduce stress. Depression, which is abnormal after surgery, can affect wound healing. It is not advisable to encourage the client to do everything alone at home to build strength, as this could be dangerous if the client is not physically capable.

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

B) "It provides a way to remove drainage and blood from the surgical wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical site. It does not provide a route for medication administration or decrease the chance for infection, nor does it stay attached permanently.

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

B) "Very little scar tissue will form." Explanation: Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff 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? A) Use an aquathermia pad during the treatment to create heat and circulate the water. B) Administer analgesics 30 minutes prior to the treatment to act on pain receptors. C) Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. D) Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles.

B) Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Explanation: Warm soaks and dressing changes can be painful for clients with abscesses. Often, nurses will premedicate with pain medications, often narcotics, 20 to 30 minutes prior to make the treatments more comfortable for clients. Increasing client comfort can increase effectiveness by allowing the nurse time to adequately perform the treatment, assess the wound, and apply the new dressing. Aquathermia pads are used to promote wound healing, but they are not used simultaneously with water therapies. Dangling the legs and ambulating will not increase comfort.

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

B) Apply moist saline compresses to loosen crusts before attempting to remove the staples. Explanation: When attempting to remove surgical sutures with dried blood on them, the nurse should first apply moist saline compresses to loosen the crusts before attempting to remove the sutures. Just removing the staples without addressing the dried blood will make the procedure more uncomfortable for the client. The nurse does not need to notify the health care provider, because this is a common finding and the nurse does not need a prescription to remove the dried blood with moistened gauze. Warm compresses are not needed in this instance to remove the dried blood; also, they require a prescription from the health care provider.

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? A) Morse scale B) Braden scale C) FLACC scale D) Glascow scale

B) Braden scale Explanation: The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glascow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls.

The nurse is caring for an older adult client in a long-term care facility. Shat nurse action is important to maintain skin integrity? A) Use soap liberally when bathing B) Clean perineal area daily but do not bathe full body on a daily basis C) Check pressure points for redness after 60 minutes D) Limit fluid intake

B) Clean perineal area daily but do not bathe full body on a daily basis Explanation: Because activity of the sebaceous and sweat glands decreases, the skin will become dryer and the client may have pruritis. The perineal area should be washed daily but the nurse should avoid full bathing of the body on a daily basis. Harsh soaps should be avoided and only used sparingly. The fluid intake should be increased unless otherwise contraindicated by medical condition. Pressure points are not related to the action of sebaceous and sweat gland activity, but the pressure points should be checked for redness after 30 minutes.

Which action should the nurse perform when applying negative pressure wound therapy? A) Irrigate the wound thoroughly using normal saline and clean technique. B) Cut foam to the shape of the wound and place it in the wound.

B) Cut foam to the shape of the wound and place it in the wound. Explanation: When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

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? A) Document the findings in the client's medical record. B) Discontinue the therapy and assess the client. C) Gently rub and massage the area to warm it up. D) Notify the health care provider of the findings.

B) Discontinue the therapy and assess the client. Explanation: The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.

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? A) Banana B) Fish C) Green beans D) Pasta salad

B) Fish Explanation: To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

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 action should the nurse perform in obtaining a wound culture? A) Utilize the culture swab to obtain cultures from multiple sites. B) Keep the swab and the inside of the culture tube sterile. C) Stroke the culture swab on surrounding skin first. D) Cleanse the wound after obtaining the wound culture.

B) Keep the swab and the inside of the culture tube sterile. Explanation: The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

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

B) Local capillary pressure must be lower than external pressure. Explanation: Local capillary pressure must be higher than external pressure for adequate skin perfusion.

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) 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

B) Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Explanation: 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.

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) Using sterile technique, debride the wound. B) Off-load pressure from the heel. C) Contact the surgeon for debridement. D) Place an antiembolism stocking on the client's leg.

B) Off-load pressure from the heel.

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? A) Wound pouching B) Penrose drain C) Jackson-Pratt drain D) Hemovac drain

B) Penrose drain Explanation: Penrose drains are commonly used after a surgical procedure or to drain an abscess. Jackson-Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is typically placed into a vascular cavity where blood drainage is expected after surgery, and wound pouching is used on wounds that have excessive drainage.

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) Subcutaneous tissue C) Muscle layer D) Dermis

B) Subcutaneous tissue Explanation: 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.

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

B) Tearing of a structure from its normal position Explanation: 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.

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

B) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. Explanation: A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.

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

B) True Explanation: A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

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

B) albumin 2.5 mg/dL

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

B) an obese woman with a history of type 1 diabetes Explanation: Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care? A) cleanse the wound from the outer area toward the inner area B) cleanse with a new gauze for each stroke C) cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing D) cleanse the wound in parallel strokes from the top to the bottom of the wound

B) cleanse with a new gauze for each stroke

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

B) elevating and supporting the stump Explanation: The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

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? A) copious drainage that is blood-tinged B) foul-smelling drainage that is grayish in color

B) foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing.

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? A) "I may have staples in place for a number of days." B) "After delivery, I will have sutures in place." C) "Reinforced adhesive skin closures will hold my wound together until it heals." D) "I will not remove the staples myself."

C) "Reinforced adhesive skin closures will hold my wound together until it heals." Explanation: After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples. Reinforced adhesive skin closures are not strong enough to hold this type of wound together.

For which client would the application of a hydrocolloid dressing be most appropriate? A) A client whose surgical incision dehisced and became infected B) A client who has just undergone a cholecystectomy (gallbladder removal) C) A client who has a partial-thickness venous ulcer with moderate drainage D) A client with a sunburn affecting his back and torso

C) A client who has a partial-thickness venous ulcer with moderate drainage Explanation: Hydrocolloids are occlusive or semiocclusive dressings that limit exchange of oxygen between wound and environment; they are appropriate for partial- and full-thickness wounds with light to moderate drainage. A sunburn would not normally warrant this type of wound dressing and they are not used on infected wounds. Hydrocolloid dressings are not used on uncomplicated surgical incisions.

The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply. A) A nurse applies Telfa to a wound to keep drainage from passing through to a secondary dressing. B) A nurse places a drainage dressing around a drain insertion site. C) A nurse places a transparent dressing over a central venous access device insertion site. D) A nurse places a Surgipad directly over an incision. E) A nurse places a transparent dressing over an ABD pad to help keep the wound dry. F) A nurse uses aseptic techniques when changing a dressing.

C) A nurse places a transparent dressing over a central venous access device insertion site. F) A nurse uses aseptic techniques when changing a dressing. B) A nurse places a drainage dressing around a drain insertion site. Explanation: The nurse would place an OpSite over a central venous access device insertion site. An OpSite helps to secure the device and is appropriate for a site with little drainage. The nurse would use appropriate aseptic techniques when changing a dressing. The nurse would place a drainage dressing around a drain insertion site. The dressing absorbs drainage and protects the wound from contamination or injury. The nurse would not place a transparent dressing over an ABD pad. The nurse would use tape on the ABD pad. Drainage could be marked on the tape to determine any changes in drainage. The purpose of a Telfa is to not adhere to the wound, and allows drainage to pass through to a secondary dressing.

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

C) An infant's skin and mucous membranes are easily injured and at risk for infection. Explanation: An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

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) Necrosis B) Evisceration C) Desiccation D) Maceration

C) Desiccation Explanation: 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.

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse? A) Leave the therapy on for 10 more minutes and return to remove it after that time. B) Explain to the client that this is not possible because of the health care provider's prescription. C) Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. D) Assist the client to get out of bed and sit up in a chair for a short while.

C) Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. Explanation: The best response by the nurse is to explain the possible complications of leaving cold therapy in place for too long, including cell death and tissue necrosis. This response not only answers the client's question but teaches at the same time the rationale and reason for limiting the cold therapy. Leaving the therapy on for 10 more minutes places the client at increased risk of tissue injury. Assisting the client out of bed ignores the client's request. Using the health care provider's prescription as the reason displays lack of understanding by the nurse and does not aid the client in understanding the rationale for the time limit.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? A) Carefully pick the crusts off the sutures with the forceps before removing them. B) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. C) Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. D) Do not attempt to remove the sutures because the wound needs more time to heal.

C) Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

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? A) Stage IV B) Stage I C) Stage II D) Stage III

C) Stage II Explanation: A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action? A) Stop the sitz bath and help the client ambulate back to the client room. B) Reassure the client that this is a normal effect of a sitz bath and monitor the client closely. C) Stop the sitz bath, call for help, and help the client to the toilet to sit down. 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. Explanation: 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.

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

C) The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. Explanation: The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client's neck. The nurse would not cover the heating pad with a heavy blanket.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? A) The nurse swabs the wound from the bottom to the top. B) The nurse uses friction when cleaning the wound to loosen dead cells. C) The nurse works outward from the wound in lines parallel to it. D) The nurse swabs the wound with povidone-iodine to fight infection in the wound.

C) The nurse works outward from the wound in lines parallel to it. Explanation: A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty.

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? A) Staging the wound for assessment B) The event leading up to the trauma C) The status of the client's tetanus immunization D) If there is contamination of dirt and debris

C) The status of the client's tetanus immunization Explanation: Staging the wound is only done with pressure injuries. The presence of dirt or debris is something that will need to be addressed, but not the most important assessment. Understanding how the client stepped on the nail will need to be noted and is a possible educational opportunity for prevention, but it is not the most important assessment concern. Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defence against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? A) a client who lifts himself up on his elbows B) a client who lies on wrinkled sheets C) a client sitting in a chair who slides down D) a client who must remain on his back for long periods of time

C) a client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

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) an older client with arthritis B) a newborn C) a critical care client D) a client with cardiovascular disease

C) a critical care client Explanation: 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.

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to? A) depression B) urinary incontinence C) decubitus ulcer D) bowel obstruction

C) decubitus ulcer Explanation: Many factors predispose an individual to pressure injuries; factors can be physical (local infections, malnutrition), functional (impaired mobility, incontinence), or psychosocial (poor adherence to treatment, impaired cognition).

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? A) abrasion B) laceration C) incision D) avulsion

C) incision Explanation: An incision is a clean separation of skin and tissue with smooth, even edges. Therefore the nurse documents the finding as an incision. In an avulsion, large areas of skin and underlying tissue have been stripped away. An abrasion involves the stripping of the surface layers of skin. A laceration is a separation of skin and tissue with torn, irregular edges. Therefore the nurse does not document the finding as an avulsion, abrasion, or laceration.

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? A) "Dehiscence is a total separation of the wound with protrusion of the viscera through it." B) "Dehiscence is the softening of tissue due to excessive moisture." C) "Dehiscence is not anything that you need to worry about." D) "Dehiscence is when a wound has partial or total separation of the wound layers."

D) "Dehiscence is when a wound has partial or total separation of the wound layers." Explanation: 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.

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 works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." C) "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." D) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

D) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." Explanation: 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.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? A) As a stage III pressure injury B) As a stage IV pressure injury C) As a stage II pressure injury D) As a stage I pressure injury

D) As a stage I pressure injury Explanation: Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV.

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? A) Frequently orient client to place and situation B) Perform passive range-of-motion exercises C) Massage skin surfaces daily, especially areas under pressure and bony prominences D) Implement a 2-hour repositioning schedule

D) Implement a 2-hour repositioning schedule Explanation: The nurse must regularly turn and reposition the client who is immobile to prevent ischemia and consequent skin breakdown. Other skin integrity interventions include monitoring skin for changes, monitor client's continence status and prevent or minimize exposure to urine and feces, evaluate need for positioning devices and specialty mattresses, nutritional status assessment, and individualize skin care plan. Range-of-motion exercises are good to combat problems related to immobility. Frequent orientation is helpful for clients with dementia. Massage may promote circulation, but it is less important than turning the client on a scheduled basis, and massaging areas over bony prominences could harm the skin's integrity.

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day? A) The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain. B) The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain. C) The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain. D) The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors.

D) The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. Explanation: Sometimes the physician orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? A) The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. B) The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. C) The wound is a 3 × 5-cm blood-filled blister. D) The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

D) The wound is 3 × 5 cm, with yellow tissue covering the entire wound. Explanation: The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.

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

D) Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Explanation: 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.

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

D) a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.

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

D) a surgical incision with sutured approximated edges Explanation: Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? A) a gauze dressing precut halfway to fit around the IV line B) a gauze dressing premedicated with antibiotics C) a dressing with a nonadherent coating D) a transparent film

D) a transparent film Explanation: Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms. Gauze dressings--precut, with an adherent coating, premedicated with antibiotics--do not allow the nurse to visualize the site without partially or completely removing the dressing.

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

D) dehiscence. Explanation: 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.

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) maturation phase B) inflammatory phase C) hemostasis D) proliferation phase

D) proliferation phase Explanation: 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.

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

D) removing dead or infected tissue to promote wound healing Explanation: Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

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: A) third degree or full thickness B) fourth degree or fat layer C) first degree or superficial D) second degree or partial thickness

D) second degree or partial thickness Explanation: Partial-thickness burns may be superficial or moderate to deep. A superficial partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good example. Moderate to deep partial-thickness burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present. The full-thickness burn appears dry and leathery.

Which best describes the proliferative phase, the third phase of the wound healing process?

reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization Explanation: 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.

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?

secondary intention Explanation: 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.