PrepU quizzes Chapter 32: Skin Integrity & Wound Care

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

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

"Do you experience incontinence?"

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

"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.

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?

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

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."

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.

"Very little scar tissue will form." "Your wound edges are right next to each other." "This is a simple reparative process."

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."

Which is not considered a skin appendage? -Hair -Connective tissue -Sebaceous gland -Eccrine sweat glands

-Connective tissue Explanation: Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?

Albumin 2.8 mg/dL (28.0 g/L)

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

An infant's skin and mucous membranes are easily injured and at risk for infection.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

Apply saline solution-moistened gauze over the protruding area.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside.

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? -Desiccation -Maceration -Necrosis -Evisceration

Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is the death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

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?

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?

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II

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

True

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

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?

The status of the client's tetanus immunization

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection?

foul-smelling drainage that is grayish in color

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

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

transparent

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

transparent Explanation: Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist.

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 in the postanesthesia care unit (PACU) is assessing a new client who has just undergone abdominal exploratory laparotomy. Which response should the nurse prioritize after noting the SaO2 is 95% (0.95), blood pressure is 128/80 mm Hg, cardiac monitor is showing rare premature atrial contractions (PAC), and drainage on abdominal dressing is approximately 5 cm × 3 cm of pinkish drainage along the lower edge of the dressing?

apply additional dressing, especially over the lower edge where drainage is occurring

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 transparent film

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?

As a stage I pressure injury

Which is not considered a skin appendage?

Connective tissue

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change.

- Use sterile gloves. - Cut the foam to the shape and measurement of the wound. - Place the drape to cover the wound and an additional 3 to 5 cm. - Cut a 2-cm hole in the drape. - Apply a vacuum device to wound. - Ensure that negative pressure has been achieved.

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus

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

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.

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

Rotate the swab several times over the wound surface to obtain an adequate specimen. 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 postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence.

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.

- No finger numbness or tingling - Fingers with quick capillary refill - Warm hand

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply. -The nurse makes more frequent checks of the skin of an older adult using a heating pad. -The nurse places a heating pad on a sprained wrist that is in the acute stage. -The nurse instructs the client to lean or lie directly on the heating device. -The nurse fills an ice bag with small pieces of ice to about two-thirds full. -The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. -The nurse applies moist cold to a client's eye for 40 minutes every 2 hours.

-The nurse makes more frequent checks of the skin of an older adult using a heating pad. -The nurse fills an ice bag with small pieces of ice to about two-thirds full. -The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. Explanation: The nurse would make more frequent checks of the skin of an older adult using a heating pad. The nurse would fill an ice bag with small pieces of ice to about two-thirds full. The nurse would cover a cold pack with a cotton sleeve to keep it in place on an arm. The nurse would place cold therapy, not a heating pad, on a sprained wrist in the acute stage. The nurse would instruct the client not to lie or lean directly on the heating device. The nurse would apply moist cold to a client's eye for 30 minutes, not 40 minutes, every 2 hours.

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

Black classification Explanation: A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System.

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? -primary intention maturation -secondary intention -tertiary intention

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.

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

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.