PrepU - Foundations

A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?

the client's pain based on a pain rating

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?

"That is necrotic tissue, which must be removed to promote healing."

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include?

"Very little scar tissue will form."

contusion

(n.) bruise, injury (The contusions on his face suggested he'd been in a fight.)

The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

Assess the wound for active bleeding.

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 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?

Elevate and support the stump

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which of the following actions should the nurse perform in obtaining a wound culture?

Keep the swab and inside of the culture tube sterile.

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 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should the nurse prioritize in order to minimize the client's chance of skin breakdown?

Reposition the client on a regular basis.

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound?

Secondary intention

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 applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

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

Which is not considered a skin appendage?

connective tissue

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dihiscence

One of the first signs of infection

elevated white blood count

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar.

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

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

impetigo

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

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

support the client from sliding in bed