Skin Integrity and Wound Care - Basics

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

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

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? "I will put a layer of cloth between my skin and the ice pack." "I should keep this on my ankle until it is numb." "I can let this stay on my ankle an hour at a time." "I must wait 15 minutes between applications of cold therapy."

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

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? "You will receive medication through this device." "Drainage will occur by gravity and capillary action." "It provides a way to remove drainage and blood from the surgical wound." "The bulb-like system will stay in place permanently after your mastectomy."

"It provides a way to remove drainage and blood from the surgical wound."

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."

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

"Very little scar tissue will form."

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

"Your wound will heal slowly as granulation tissue forms and fills the wound."

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Maturation 2Hemostasis 3Inflammatory 4Proliferation

1 Hemostasis 2 Inflammatory 3 Proliferation 4 Maturation

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 fungal infection accompanied by pruritus Superficial contusion accompanied by pruritus Superficial abscess accompanied by pruritus Diffuse dermatitis accompanied by pruritus

Diffuse dermatitis accompanied by pruritus

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

Discontinue the therapy and assess the client.

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

Discontinue the therapy and assess the client.

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy? Every 48 to 72 hours Every 8 to 12 hours Every 12 to 24 hours Every 25 to 36 hours

Every 48 to 72 hours

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. Do not attempt to remove the sutures because the wound needs more time to heal. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Carefully pick the crusts off the sutures with the forceps before removing them.

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

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. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. 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 surface to obtain an adequate specimen.

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

The status of the client's tetanus immunization

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

True

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention? Stop irrigating when the solution from the wound turns light pink. If new bleeding is noted, continue irrigation cautiously and then notify the health care provider. Apply petroleum jelly to the periwound skin to protect it from the irrigation solution. Use clean technique instead of sterile technique if the wound is closed.

Use clean technique instead of sterile technique if the wound is closed.

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. Warm hand Fingers with quick capillary refill Decreased radial pulse No finger numbness or tingling Cyanosis

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

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

a surgical incision with sutured approximated edges

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 gauze dressing premedicated with antibiotics a gauze dressing precut halfway to fit around the IV line a transparent film a dressing with a nonadherent coating

a transparent film

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 client whose breast reconstruction surgery required numerous incisions A client who is NPO (nothing by mouth) following bowel surgery a man with a sedentary lifestyle and a long history of cigarette smoking

an obese woman with a history of type 1 diabetes

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing? alginate hydrocolloid hydrogel transparent film

hydrocolloid

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

removing dead or infected tissue to promote wound healing

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

removing dead or infected tissue to promote wound healing

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

tertiary intention

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. A child's skin becomes less resistant to injury and infection as the child grows. In children younger than 2 years, the skin is thicker and stronger than in adults. An individual's skin changes little over the life span.

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

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

Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. Change the dressing midway between meals. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound.

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 in a circular pattern, beginning on the perimeter of the wound. Clean the wound from the top to the bottom and from the center to outside. Use clean technique to clean the wound. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

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