Tissue Integrity NUR1119

The use of interventions related to prevention of pressure injuries can not be delegated to UAP (unlicensed assistive personnel) and/or the LPN.

False

A nurse is assessing a client with a stage 4 pressure injury. What assessment of the injury would be expected?

Full-thickness skin loss

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?

Hydrocolloid

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?

Mechanical debridement

A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn?

Moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

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

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."

Which intervention(s) should the nurse include in the client's plan of care to prevent pressure injuries? Select all that apply.

-Administer nutritional supplements as ordered -Reposition and turn the client every 2 hours -Ensure any linens or skin applications such as dressing or elastic stocking do not have any wrinkles or folds -Cleanse the skin routinely and promptly if incontinent episodes and apply a barrier cream -Apply an alternating pressure pad to the bed of a client who is at risk for developing pressure injuries

Which are recommended when applying ice bags on a client? Select all that apply.

-Cover the bag with a cloth to protect skin and absorb moisture. -Apply for 30 minutes then remove it for an hour. -Teach the client to use a frozen bag of peas at home to substitute for an ice bag. -Remove an excess air from the bag

Which factor(s) can adversely affect the healing of a wound? Select all that apply.

-Dehydration or overhydration -Taking corticoidsteroids -Pressure -Presence of eschar -Infection

Basic principles related to integrity of the skin and mucous membranes include: -unbroken healthy skin and mucous membranes as our first line of defense -our resistance to injury of the skin & mucous membranes vary among people & certain factors influence resistance according to a person's age, the amount of underlying tissues, & illness conditions -nutrition & hydration of the cells help with resistance to injury -adequate perfusion and circulation to maintain cell life is necessary...when it is impaired cells die and can't remove wastes. Identify factors that can affect skin integrity:

-Developmental consideration: Age -Changes in health state: Malnutrition -Lifestyle barriers: Occupation -Illness: Diabetes -Diagnostic procedures: GI cleansing prep -Therapeutic measures: Medication or radiation

Who is at risk for pressure injury development? Select all that apply.

-Immobility -Malnourished -Dehydration or edema -Excessive moisture

The nurse understands that clients with malnutrition require special diet considerations. Which should be included in the plan of care for a client with skin breakdown? Select all that apply.

-Increase diet in protein and calories -Add vitamin C supplements orally daily -Administer zinc PO daily

What are some wound complications? Select all that apply.

-Infection -Hemorrhage -Dehiscence and evisceration -Fistula formation

Which are appropriate action(s) when collecting a wound culture? Select all that apply.

-Keep the swab sterile by avoiding touching anything other than the wound. -Identify a 1 cm area of the wound that is free from necrotic tissue. -Use a cotton tipped culturette to obtain a wound specimen. -Avoid touching the culturette to the intact skin at the wound edges.

Which action(s) are appropriate when cleansing this wound and removing sutures? Select all that apply.

-Perform hand hygiene before and after removal -Remove every other suture to be sure the wound edges are healed; then remove remaining sutures if wound edges appear healed -Apply butterfly sutures (sterile-strips) as ordered -Using forceps to lift the suture knot and clip one side of the suture with sterile scissors

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound?

Stage 2 pressure injury

When is applying heat contraindicated? Select all that apply.

-To an open wound immediately after trauma -To an area that is hemorrhaging -Over an acutely inflamed area -To a pregnant woman's abdomen -To the testicles -On a metal implant such as an implanted cardiac defibrillator

Which should be included in measuring wounds and pressure injuries? Select all that apply.

-Use a moistened sterile swab (cotton tipped applicator) with saline & insert it into the wound @ a 90 degree angle with the tip down. -Mark the swab even with skin surface with fingers to note the depth of the wound. -Use a disposable measuring device to meausre the size of the wound including (length, width, diameter, and depth). -Determine the direction of any tunneling with a moist swab. -Use standard precautions and transmission based precautions if infectious. -Insert the moistened swab in the wound tunnel and note the depth even with the wound edges.

The HCP had ordered a cold ice bag to be applied to the wrist of a client with a sprain. The nurse will ensure that the cold application is at what temperature before application?

10-18.3 degree C (50-65 degree F)

What is the correct order of the phases of wound healing? 1. Inflammatory Phase 2. Maturation Phase 3. Proliferation Phase 4. Hemostasis

4,1,3,2

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

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one wound be most at risk?

An 86 year old who is bedfast

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?

Assessing the wound for active bleeding

A full-thickness or third-degree burn develops a leathery covering called

Eschar

Sanguineous Drainage

Bright red when there is fresh bleeding and darker if bleeding is older

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

Serous Drainage

Clear and Watery

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?

Contusion

The RN can delegate removal of eschar to the LPN or another RN.

False

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 med-surg 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

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage

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?

Document the findings

When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Perform hand hygiene

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

Primary intention

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Proliferation phase

A med-surg 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 caring for a client who has reported to the ED with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely

Second-degree or partial thickness

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?

Serosanguineous

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

Stage 2

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2cm x 5cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

Stage 3

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?

Supports the area around the wound

A client limps in the ED 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?

Tetanus, infection, wound care, and pain control

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 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?

The wound is 3x5 cm, with yellow tissue covering the entire wound

Purulent Drainage

Thick, musty or foul in odor, and is usually dark yellow or green depending on the cause

The RN can delegate wound care to the LPN.

True

Wound contamination occurs through a moist medium; microorganisms can move from the external surface through the dressing into the wound when a dressing remains saturated in place.

True

A nurse is caring for a client with a non healing stage 4 pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?

Undermining

Serosanguineous Drainage

Usually bloody tinged or light pink in color

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?

White blood cells, debris, bacteria

Which color wound requires use of wound cleansers and irrigation of the wound?

Yellow