Taylor Chapter-31 skin integrity and wound care
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? A. "Do you experience incontinence?" B. "Have you had any recent illnesses?" C. "Do you use any lotions on your skin?" D. "How many meals a day do you eat?"
"Do you experience incontinence?" Explanation: The client's health history is an essential component for assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about skin care regimens, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.
The nurse is caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states, "My pain medication is effective, but will this pain ever get better and go away?" Which response is correct? A. "It is unusual for you to still have severe pain. I will contact your surgeon." B. "If the pain does not subside by this time tomorrow, you will need to be screened for the development of chronic pain." C. "If the prescribed analgesics are controlling the pain, we do not worry about the severity of the pain." D. "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe."
"Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." Explanation: Surgical incisional pain is usually most severe for the first 2 to 3 days and then progressively diminishes. It is imperative that nurses teach clients about the progression of pain postsurgery. The client should still be assessed for pain and the pain scale should be documented in the client's medical record. The development of chronic pain is persistent pain after 6 months.
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. "I place antibiotic ointment in the bulb and squeeze it into the wound." B. "The drain is part of the knee replacement; it stays attached permanently." C. "It allows for removal of blood and drainage from the surgical wound." D. "This drain decreases the pain associated with the knee replacement."
"It allows for removal of blood and drainage from the surgical wound." Explanation: The bulb-like drain allows for removal of blood and drainage from the surgical wound. It does not decrease the pain level, nor does it stay attached permanently. The nurse empties the drain, but does not place medication inside it. Reference:
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. "The bulb-like system will stay in place permanently after your mastectomy." B. "You will receive medication through this device." C. "It provides a way to remove drainage and blood from the surgical wound." D. "This drain minimizes the chance for bacteria to enter the surgical site."
"It provides a way to remove drainage and blood from the surgical wound." Explanation: The bulb-like drain allows for removal of blood and drainage from the surgical site. It does not provide a route for medication administration, decrease the chance for infection, nor does it stay attached permanently.
The nurse and client are looking at a client's heel pressure injury. The client states, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? A. "That is called slough, and it will usually fall off." B. "You are seeing undermining, a type of tissue erosion." C. "This is normal tissue." D. "Necrotic tissue is devitalized tissue that must be removed to promote healing."
"Necrotic tissue is devitalized tissue that must be removed to promote healing." Explanation: The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. 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 has undergone an open surgical procedure. Which teaching provided by the nurse accurately reflects what the client should expect during the remodeling period? A. "The wound will contract and scarring will shrink." B. "Neurophils and monocytes will migrate to the site of your incision." C. "Granulation tissue will start to form." D. "Blood vessels will constrict to control blood loss."
"The wound will contract and scarring will shrink." Explanation: Constriction of blood vessels and appearance of polymorphonuclear leukocytes takes place during the inflammation period. Granulation tissue forms during the proliferation period. The surgical wound contracts and scarring shrinks during the remodeling period.
The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include? A. "This is a complex reparative process." B. "Very little scar tissue will form." C. "The margins of your wound are not in direct contact." D. "The surgeon will leave your wound intentionally open for a period of time."
"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 where margins of the wound are not in direct contact. Third-intention healing takes place when wound edges are intentionally left widely separated and are later brought together for closure.
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. A. "This is a simple reparative process." B. "The margins of your wound are widely separated." C. "Your wound edges are right next to each other." D. "Very little scar tissue will form." E. "Your wound will be purposely left open for a time period."
"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other." Explanation: Very little scar tissue is expected to form during first-intention healing in a wound where wound edges are close to each other. Second-intention healing involves a complex reparative process where margins of the wound are not in direct contact. Third-intention healing takes place when wound edges are intentionally left widely separated and are later brought together for closure. Reference:
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. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." C. "As soon as the infection clears, your surgeon will staple the wound closed." D. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."
"Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: This statement is correct as 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 and this is not done if less scar is neccesary. Third intention is when a wound is left open for a few days and then if there is no indication of infection, the surgeon closes the wound.
A client has a fissure on her finger due to chafing. The client asks "How long will it be painful?" The nurse explains that the inflammation phase will last: A. 5 days. B. 7 days. C. 3 days. D. 2 weeks.
3 days. Explanation: The inflammation phase of a partial thickness wound lasts approximately 3 days.
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains? A. A Penrose drain is a closed drainage system that is connected to an electronic suction device. B. A Penrose drain promotes drainage passively into a dressing. C. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. D. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.
A Penrose drain promotes drainage passively into a dressing. Explanation: A Penrose drain is an open drainage system that promotes drainage of fluid passively into a dressing. Additional drains include the Jackson-Pratt drain that 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 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? A. White blood cell count 14,800 mm3 (14.8 x 109/L) B. Hemoglobin A1C 5% C. Albumin 2.8 mg/dL (28.0 g/L) D. Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L)
Albumin 2.8 mg/dL (28.0 g/L) Explanation: An albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure injury. This indicates that the client is nutritionally deficient. The hemoglobin A1C level of 5% is a normal value. The BUN level is within normal limits. The white blood cell count is also a normal value.
The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? A. Assess the client for claustrophobia. B. Assess for the use of antihypertensives. C. Assess the wound for active bleeding. D. Assess the client's mental status.
Assess the wound for active bleeding. Explanation: Negative-pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed. NPWT is not considered for the use in the presence of active bleeding. The nurse needs to assess for the use of anticoagulants, not antihypertensives, because these can cause bleeding. Mental status and the presence of claustrophobia are not significant when initiating negative-pressure wound therapy.
Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. A. Avoid touching the wound bed, whether with gloves or forceps. B. Clean the wound from top to bottom. C. Use a sterile applicator to apply any ointment that is ordered. D. Use a new gauze for each wipe of the wound. E. Clean from the outside of the wound to the center.
B. Clean the wound from top to bottom. C. . Use a sterile applicator to apply any ointment that is ordered. D. Use a new gauze for each wipe of the wound. A. Avoid touching the wound bed, whether with gloves or forceps. Explanation: Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps.
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? A. Enzymatic debridement B. Mechanical debridement C. Autolytic debridement D. Biosurgical debridement
Biosurgical debridement Explanation: Biosurgical debridement uses fly larvae to clear the wound of necrotic tissue. This is accomplished through 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, such as surgical debridement.
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? A. Yellow classification B. Red classification C. Black classification D. 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 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? Morse scale B. FLACC scale C. Glascow scale D. Braden scale
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.
A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care? A. Cleanse the wound using parallel stroke from the top to the bottom of the wound. B. Cleanse the wound from the outer area towards the inner area. C. Cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing. D. Cleanse with a new gauze for each stroke.
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 using 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 Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
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.
The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood? A. OpSite B. Tegasorb C. Gauze D. Duoderm
Gauze Explanation: Gauze dressings absorb blood or drainage. Transparent dressings like OpSite are used to protect intravenous insertion sites. Hydrocolloid dressings like Duoderm and Tegasorb are used to used keep a wound moist.
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. 3-Hemostasis 2-Inflammatory 1-Proliferation 4-Maturation
Hemostasis Inflammatory Proliferation Maturation Explanation: The correct order of the phases of wound healing is hemostasis, inflammatory, proliferation, and maturation.
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? A. Laxatives B. Corticosteroids C. Potassium supplements D. Antihypertensive drugs
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 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. Evisceration of the viscera B. Herniation of the wound C. Dehiscence of the wound D. Infection of the wound
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.
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? A. Direction B. Tunneling C. Size D. Depth
Depth Explanation: When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.
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. Maceration B. Evisceration C. Desiccation D. Necrosis
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.
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. Document the findings. C. Change the dressing. D. Notify the wound care nurse.
Document the findings. Explanation: The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is no need to contact the health care provider or the wound care nurse. The nurse should not change the surgical dressing. Most often, the surgeon will change the first dressing in 24 to 48 hours. For this reason, the wound care nurse does not need to be notified.
When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse? A. Notify the physician. B. Consult a wound care nurse. C. Document the findings. D. Send the client to the emergency room.
Document the findings. Explanation: The nurse should document the findings. The red tissue that bleeds easily is granulation tissue, a key part of the healing process. As the wound is healing, there is no need to contact the physician or the wound care nurse. There is also no need to send the client to the emergency room. Reference:
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. Wrap distally to proximally. B. Keep bandage free from gaps between each turn. C. Elevate and support the stump. D. Exert equal, but not excessive, tension with each turn of the bandage.
Elevate and support 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.
The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?
Impaired tissue integrity Explanation: Using the A, B, C (Airway, Breathing, Circulation) mnemonic, impaired tissue integrity takes priority. Using Maslow's Hierarchy of Needs, impaired tissue integrity also takes priority. Disturbed body image, knowledge deficit, and acute pain are all important issues that need to be addressed, but ensuring there is proper circulation to the surgical area, the surgical area is free of signs of infection, and the surgical area is intact is priority.
A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client? A. Enzymatic debridement B. Autolytic debridement C. Biosurgical debridement D. Mechanical debridement
Mechanical debridement Explanation: Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. 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.
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. Contact the surgeon for debridement. B. Using sterile technique, debride the wound. C. Off-load pressure from the heel. D. Place an antiembolism stocking on the client's leg.
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.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? A. Use less packing material. B. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. C. Assure that the packing material is completely saturated when placed in the wound. D. Reduce the time interval between dressing changes.
Reduce the time interval between dressing changes. Explanation: Reducing the time interval between the dressing changes allows for the dressing change to occur without causing pain and promoting secondary intention. If the dressing becomes dry, the more pain the client experiences and damage to the newly formed epithelial and granulating tissue. The packing material should be completely saturated when placed in the wound. Using less packing material impairs secondary intention. A hydrocolloid dressing is not indicated.
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? A. Desiccation B. Secondary intention C. Tertiary intention D. Primary intention
Secondary intention Explanation: The client with a wound dehiscence will undergo wound repair by secondary intention. In these wounds, the wound edges are not well approximated and will require more tissue replacement. Primary intention involves wound edges that are well approximated or close together. Tertiary intention involves wounds that are left open for a period of time and then closed. Desiccation is a process where cells are dehydrated. This leads to cell death and delays healing.
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 types should the nurse document? A. Purulent B. Sanguineous C. Serosanguineous D. Serous
Serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. 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.
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 types should the nurse document? A. Purulent B. Serous C. Serosanguineous D. Sanguineous
Serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. 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.
The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care? A. Soak in a warm bath for drainage. B. Cleanse labia with scented soap. C. Expose the area to a heat lamp. D. Apply an ice pack to relieve pain.
Soak in a warm bath for drainage. Explanation: Heat promotes vasodilation, allowing for the consolidation of pus in infected areas. Scented products may contain chemicals that promote irritation to the infected area and have no curative benefits to this particular client. Cold application will result in vasoconstriction and will not promote 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 II C. Stage III D. Stage I
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 nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? A. Stage I B. Stage IV C. Stage II D. Stage III
Stage III Explanation: Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscles.
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury? A. Stage IV B. Stage II C. Stage I D. Stage III
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.
Question 10 See full question 10s The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury?
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 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. Muscle layer C. Subcutaneous tissue D. Dermis
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.
Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure injury? A. Improve the client's hydration. B. Lubricate the area with skin oil. C. Pull client up under the arms. D. Support the client from sliding in bed.
Support the client from sliding in bed. Explanation: Shearing force occurs when tissue layers move on each other, causing vessels to stretch as they pass through the subcutaneous tissue.
A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? A. Keeps the wound clean B. Maintains a moist environment C. Supports the area around the wound D. Reduces swelling and inflammation
Supports the area around the wound Explanation: Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wrapped on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist.
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. Tearing of a structure from its normal position B. Tearing of the skin and tissue with some type of instrument; tissue not aligned C. Puncture of the skin D. Cutting with a sharp instrument with wound edges in close approximation with correct alignment
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 preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? A. Tegaderm B. Montgomery straps C. DuoDerm D. gauze
Tegaderm Explanation: Transparent dressings like Tegaderm are used to protect intravenous insertion sites. Montgomery straps are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings like DuoDerm are used to used keep a wound moist.
The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? A. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. B. The nurse packs the wound cavity tightly with dressing material. C. The nurse uses wet-to-dry dressings continuously. D. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown.
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.
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 uses friction when cleaning the wound to loosen dead cells. B. The nurse works outward from the wound in lines parallel to it. C. The nurse swabs the wound with povidone-iodine to fight infection in the wound. D. The nurse swabs the wound from the bottom to the top.
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.
A client with anorexia nervosa has developed a pressure injury on the sacrum. Which laboratory result would indicate the client is at nutritional risk? A. Albumin level of 3.5 mg/dL (35 g/L) B. Total lymphocyte count of 1,500/mm3 (1.50 x 109/L) C. Body weight decrease of 3% D. Arm muscle circumference 90% of standard
Total lymphocyte count of 1,500/mm3 (1.50 x 109/L) Explanation: The following laboratory criteria indicate that a client is nutritionally at risk for development of a pressure injury: albumin level <3.2 mg/dL (normal, 3.5-5 mg/dL), prealbumin <19 mg/dL (normal 16-40 mg/dL), body weight decrease of 5% to 10%. Additional laboratory tests to consider in clients at risk for or presenting with pressure injuries include: total lymphocyte count <1,800/mm3 (normal, 1,000- 4,000/mm3), hemoglobin A1C >8% (normal <6%), glucose >120 mg/dL (normal 70-120 mg/dL). Although one of the options is body weight decrease of 5%, it is not the best answer. The best answer is total lymphocyte count of 1,500/mm3.
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. Hydrocolloid B. Bandage C. Gauze D. Transparent
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 wounds moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? A. Provide incontinent care every 4 hours as needed. B. Use pillows to maintain a side-lying position as needed. C. Elevate the head of the bed 90 degrees. D. 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 to the skin. A foot board prevents footdrop in clients but does not decrease the risk for pressure injury.
A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? A. Wound irrigation B. Debridement C. Gentle cleansing D. Apply moist dressing
Wound irrigation Explanation: With the yellow classification using the RYB wound classification system, wound irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present.
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?
You Selected: Do not attempt to remove the sutures because they need more time to heal. Correct response: Moisten sterile gauze with sterile saline to 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 sutures. Washing the sutures with antimicrobial soap is not necessary and may decrease the clots and crusts that have formed since surgery. Picking the crusts off with sutures can be painful for the client and destroy the clot/crust formation. The sutures need to be removed and waiting is not appropriate.
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?
You Selected: The nurse swabs the wound from the bottom to the top. Correct response: 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.
When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?
You Selected: friction Correct response: shearing force Explanation: A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.
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 sitting in a chair who slides down C. a client who lies on wrinkled sheets D. a client who must remain on his back for long periods of time
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 client with cardiovascular disease C. a newborn D. a critical care client
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 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. an allergic reaction to detergent. B. a rash related to a yeast infection. C. an allergic reaction to medications. D. a rash related to immobility.
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.
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A. a wound healing naturally that becomes infected. B. a large wound with considerable tissue loss allowed to heal naturally C. a surgical incision with sutured approximated edges D. a wound left open for several days to allow edema to subside
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.
A client's risk for the development of a pressure injury is most likely due to which lab result? A. hemoglobin A1C 7% B. albumin 2.5 mg/dL C. glucose 110 mg/dL D. sodium 135 mEq/L
albumin 2.5 mg/dL Explanation: An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure injury. Hemoglobin A1C levels greater than 8% place the client at risk for the development of pressure injuries due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not place the client at risk for the development of a pressure injuries.
The nurse would recognize which client as being particularly susceptible to impaired wound healing? A. A client who is n.p.o. (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
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 is 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 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. puncture C. incision D. avulsion
contusion Explanation: A contusion is an injury to soft tissue, so this is what the nurse expects to see based on the incident. A puncture involves an opening of 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 stripped surface layers of skin. An avulsion has stripped away of large areas of skin and underlying tissues.
A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for: A. evisceration. B. herniation. C. dehiscence. D. infection.
dehiscence. Explanation: Dehiscence is a total or partial disruption in wound edges. Clients often report feeling the incision has given way. 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.
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. figure-of-eight turn B. spica turn C. circular turn D. spiral-reverse turn
figure-of-eight turn Explanation: A figure-of-eight turn is used for joints like elbows and knees. Other answers are incorrect.
Which type of wound drainage should alert the nurse to the possibility of infection? A. copious wound drainage that is blood-tinged B. drainage that appears to be mostly fresh blood C. large amounts of drainage that is clear and watery D. foul-smelling drainage that is grayish in color
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. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection.
What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? A. transparent films B. hydrocolloid dressings C. alginates D. hydrogels
hydrocolloid dressings Explanation: Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small, partial-thickness wounds with minimal drainage.
What is the best nursing diagnosis to describe a minor laceration to finger sustained when a client was cutting fruit in the kitchen with a knife? A. pain related to wound sustained by knife B. impaired skin integrity related to open wound C. risk for infection related to wound D. knowledge deficit regarding wound care related to laceration
impaired skin integrity related to open wound Explanation: Impaired skin integrity best describes the minor laceration. Pain, knowledge deficit, and risk for infection are all sustained as a result of the laceration.
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. avulsion B. incision C. laceration D. abrasion
incision Explanation: An incision involves a clean separation of skin and tissue with smooth, even edges. Therefore, the nurse documents the finding as an incision. An avulsion has stripped away of large areas of skin and underlying tissues. An abrasion involves stripped surface layers of skin. A laceration involves 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 observes the client for signs of stage I pressure injury development, which is most likely to include which finding? A. a shallow, open injury B. visible subcutaneous fat C. exposed bone with eschar D. nonblanchable redness
nonblanchable redness Explanation: A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence. A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage III pressure injury presents with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. A stage IV pressure injury involves 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 nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: A. primary intention. B. secondary intention. C. tertiary intention. D. dehiscence.
primary intention. Explanation: Wounds healing by primary intention form a clean, straight line with little loss of tissue. Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue. Wounds healing by delayed primary intention or tertiary intention are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed. Dehiscence is wound separation, not wound healing.
The spouse of a client limps into the emergency department and states, "I stepped on a nail and didn't have shoes on. Now I can barely walk." What type of injury does the nurse anticipate? A. puncture B. laceration C. avulsion D. contusion
puncture Explanation: A puncture involves an opening of skin caused by a narrow, sharp, pointed object. Therefore, the nurse anticipates the client to have a puncture, based on the description of the incident. An avulsion involves stripping away of large parts of tissue, leaving cartilage and bone exposed. A laceration involves separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue.
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 dead or infected tissue to promote wound healing B. removing excess drainage and wet tissue to prevent maceration of surrounding skin C. stimulating the wound bed to promote the growth of granulation tissue D. removing purulent drainage from the wound bed in order to accurately assess it
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.
A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: A. to provide drainage for bile. B. to provide a sinus tract for drainage. C. to divert drainage to the peritoneal cavity. D. to decrease dead space by decreasing drainage.
to provide drainage for bile. Explanation: A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.
