Wound care chapter

A nurse is reinforcing teaching with an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? The layers of the skin become detached with age. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences" Oolder adult clients have more moisture in the skin placing them at risk for maceration. O Skin changes cause the synthesis of vitamin B to decrease with age

"The skin of older adults is thinner and has less subcutaneous padding over bony prominences"

A nurse is reinforcing teaching with a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructionsby the nurse is related to preventing skin breakdown?

"You should shift your weight off your buttocks at intervals throughout the day."

characteracterisics and classifications of wounds

*bruises/contusion *closed wounds *hematoma *crush wounds *abrasions *lacerated wounds *penetrated wounds *penetrating injury *perforating wound *avulsion

crush wounds

*caused by a great or extreme amount of force applied over a long period of time *these occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures *they are often accompanied by degloving injuries and compartment syndrome

penetrated wound(punctured wound)

*caused by sharp pointed objects like nails *Have a small opening and be very deep *infection/foreign particles might have been carried deep into the wound opening is inadequate for drainage *trauma is caused by sharp objects like needles, sticks,pencils, knives , arrows pens

Bruise (contusion/ecchymosis)

*closed wounds, caused by blunt trauma that damage tissue under the skin without breaking it. *discoloration due to bleeding into the tissues *blood vessels are damaged or broken from a blow to the skin

Partial thickness wounds

*epidermis and slight part of the dermis is affected *heals by epithelialization *wound does bleed *if left uncovered, a blood clot will cover the wound and a scar will form *the missing tissue then is replaced, followed by regeneration of the epidermis *can take several days to weeks to heal, depending on the patient and the treatment chosen

perforating wounds

*have two opening one of entrance and other of exit ex: gunshot wounds

Types of wounds

*intentional -a wound that is the result of a planned invasive procedure *unintentional -a wound that is the result of unexpected trauma *open -skin surface is broken providing a portal of entrance for organisms *closed -results from a blow, force or strain trauma(fall,assault, motor vehicle accident) *acute vs chronic

Clean wound (Class I)

*no inflammation *operative wounds following blunt non-penetrating trauma *no break in sterile technique *wound primarily closed/ not drained *aero-digestive, GU and biliary tract not entered *infection rate 1% -5% Examples -mitral valve replacement -mastectomy -lipoma excision -breast biopsy

clean contaminated (class II)

*no inflammation/ infection present *operative wound enterind Respiratory,alimentary,genital, or UT *minor break in sterile technique *aerodigestive or GU tract entered wiouth spillage *potential infection rate 8 to 10% Examples appendix surgery, bilary tract, oropharynx, cholecystectomy,tonsillectomies ,cystoscopy

dirty/infected wound(IV)

*organisms present at surgical site prior to the proceduce/ existing infection *excision and drainage of abscess *delayed primary closure after ruptures appy *presence of pus *perforation(GI, bilary, respiratory, GU) *potential infection rate 27%-40% *example -appendical absecc -peritonitis -amputation for wet gangrene

abrasions

*shearing injury of the skin of skin in which the surface of the skin is rubbed off *most are superficial and will heal by epithelialization *scratch or scrape *epidermal and dermal injury caused by friction rubbing or scraping motion *no bleeding but mild pain

lacerated wound

*tearing of tissues with irregular borders *loss of tissue is limited to skin and s/c tissue *ruptue or tear or split in the skin, mocous memebrane, muscle, internal organ or underlying tissues

Contaminated (Class III)

*traumatic wounds open, fresh, accident wounds *acute inflannation present *major break in sterile technique * gross spillage/contamination from respiratory, GI tract, or GU tract during the procedure *potential infection rate 15 % - 20 % Examples amputation for dry gangrene bile spillage stab wound involving lung

Clasification of surgical wounds

-clean (class I) -clean contaminated (class II) -contaminated (class III) -dirty(class IV)

(Fa-Davis quiz assignment) The nurse checks on a postoperative patient who states, "Something just popped." When the nurse monitors the wound, the nurse finds the following (shown in the image). Which actions should the nurse take? Select all that apply. 1. Cover with a sterile dressing soaked in normal saline. 2. Take vital signs at least every 15 minutes. 3. Place in the supine position 4. Offer the patient cool water to drink. 5. Gently replace the organs back with gloved hands.

1. Cover with sterile dressing soaked in normal saline. 2. Take vital signs at least every 15 minutes.

(Fa-Davis quiz assignment) The nurse is collecting data about a patient's wound. Which findings indicate the wound is infected? Select all that apply. 1.Erythemic wound edges and surrounding area 2.Thick yellowish drainage 3.No odor from wound or drainage 4.Warmer skin temperature around wound 5.Edema 2 inches around wound

1. Erythemic wound edges and surrounding area 2. Thick yellowish drainage 4. Warmer skin temperature around wound 5. Edema 2 inches around wound

(Fa-Davis quiz assignment) The nurse is checking a postoperative patient's vital sign sheet. Based upon the findings, which action should the nurse take? 1. Position patient in low Fowler's position with knees flexed. 2. Discontinue the patient's intravenous line. 3. Have the unlicensed assistive personnel recheck vitals and report back to the nurse. 4. Notify the health-care provider after the next scheduled vital sign report.

1.Position patient in low Fowler's position with knees flexed. low Fowler's position with the knees flexed:for hemorrhage.

(Fa-Davis quiz assignment) The nurse is collecting data on a patient's wound drainage. The drainage is reddish in color. How would the nurse document this finding? 1.Sanguineous drainage present. 2. Serosanguineous drainage present. 3.Serous drainage present. 4.Purulent drainage present.

1.Sanguineous drainage present. Other terms Serous: Drainage that is clearer to slightly yellow Purulent:It is thick yellow or green drainage and is a sign of infection Serosanguineous: Pink drainage, both blood and clear drainage are present

(Fa-Davis quiz assignment) The nurse is collecting data about a patient's wound and notices that the wound is getting smaller and filling with deep pink to light red tissue. The nurse determines the patient's wound is in which phase of healing? 1. Maturation 2. Reconstruction 3. Remodeling 4. Inflammatory

2. Reconstruction Other terms to know Maturation=occurs when the wound contracts and the scar strengthens. Remodeling=where the wound contracts and extra support is provided Inflammatory=This phase occurs when the wound is fresh and includes both hemostasis and phagocytosis.

(Fa-Davis quiz assignment) The nurse obtains 100 mL of serous drainage from a Hemovac. Under which heading should the nurse chart the 100 mL? 1. Intake 2. Output 3. Emesis 4. Urine

2. output Other terms *intake:Fluid input *Emesis= the amount of vomit

(Fa-Davis quiz assignment) Which actions should the nurse take when changing a wet-to-damp dressing? Select all that apply. 1. Use dripping 4 × 4s to pack wound. 2. Fluff the 4 × 4s before placing in wound. 3. Loosely pack the 4 × 4s into the wound 4. Cover the filled wound with damp, unfluffed 4 × 4s. 5. Let the packed 4 × 4s touch skin outside the wound.

2.Fluff the 4 × 4s before placing in wound. 3.Loosely pack the 4 × 4s into the wound 4.Cover the filled wound with damp, unfluffed 4 × 4s. Other terms *Press the excess saline out of a 4 × 4 until it is moist but not dripping. Excessive moisture in the wound may cause maceration (softening) of the skin. *Do not allow the gauze to touch the skin surface outside the wound. This could cause contamination of the wound with surface microbes.

(Fa-Davis quiz assignment) The nurse is explaining to a coworker how a pressure injury occurs. The nurse should describe the process in which order? 1Reduced blood flow to the area occurs. 2Tissues receive inadequate oxygen and nutrients. 3External pressure is prolonged. 4Cells eventually necrose. 5Tissues and capillaries are compressed.

3,5,1,2,4

(Fa-Davis quiz assignment) Which statements by the nurse indicate a correct understanding of irrigating a patient's gaping wound? Select all that apply. 1. "I will touch the Angiocath sheath to attach the syringe." 2. "I will put 60 mL of irrigating solution into the syringe." 3. "I will hold the syringe about 1 inch (2.5 cm) above the wound." 4. I will spray using a back-and-forth motion." 5. I will start at the superior edge of the wound and work down to the inferior end."

3. "I will hold the syringe about 1 inch (2.5 cm) above the wound." 4. "I will spray using a back-and-forth motion." 5. "I will start at the superior edge of the wound and work down to the inferior end." Other terms Draw up 25 to 30 mL of irrigating solution into the syringe. Touch the hub of the Angiocath only. Do not touch the sheath. Attach the hub of the 19-gauge Angiocath sheath to the 35-mL syringe.

(Fa-Davis quiz assignment) The nurse is reviewing the instructions for a negative pressure wound therapy dressing for a patient's infected wound. Which statement by the nurse indicates a correct understanding of the instructions? 1. "I will use clean technique for this procedure." 2. "I will remove the old transparent dressing by pulling it away from the wound." 3. "I will make sure the dressing collapses after the pump is turned on." 4. "I will cut the foam dressing to attach the suction device."

3. "I will make sure the dressing collapses after the pump is turned on." Other terms= *Sterile technique is required unless the wound is colonized without signs of infection *Gently loosen the edges of the transparent dressing and pull it toward the wound to prevent tension on the wound edges. *Avoid cutting the foam dressing because this can result in debris in the wound and interfere with suction.

(Fa-Davis quiz assignment) Which term would the nurse use in the report to describe a patient's bruise? 1. Open wound 2. Abrasion 3. Contusion 4. Laceration

3. Contusion Other terms to know= *Open wound= A wound in which the skin integrity has been breached *Abrasion= An abrasion is a superficial open wound. such as scrapes, scratches, or rub-type wounds where the skin is broken. *Laceration= an open wound made by the accidental cutting or tearing of tissue

(Fa-Davis quiz assignment) The nurse is caring for a dark-skinned patient. The nurse suspects the patient has a stage 1 pressure injury. Which finding will help confirm the nurse's conclusion? 1. Red area 2. Purple area 3. Darkened area 4. Maroon area

3. Darkened area Other terms to know *purple and maroon area= deep tissue pressure injury

(Fa-Davis quiz assignment) The nurse is contributing to the plan of care for an emaciated, continent patient who is prone to pressure injuries. Which interventions should the nurse recommend including in the patient's plan of care? Select all that apply. 1.Turn patient every 2 hours. 2.Check incontinence pads every hour. 3.Offer protein supplements as ordered. 4.Apply gel-filled pad to bed. 5.Monitor pressure points every 1 to 2 hours.

3. Offer protein supplements as ordered. 4. Apply gel-filled pad to bed. 5. Monitor pressure points every 1 to 2 hours. 1.Turn patient every 2 hours.

(Fa-Davis quiz assignment) Evaluate the image. Which type of wound closure is the nurse describing to a patient? 1. First intention 2. Second intention 3. Third intention 4. Fourth intention

3. Third intention Other terms: First intention=When the wound is clean with little tissue loss, such as a surgical incision, the edges are approximated and the wound is sutured closed. Second intention= When there is greater tissue loss and the wound edges are irregular, the edges cannot be brought together. In these situations, the wound must be left open to gradually heal by filling in with granulation tissue, which will leave a wide scar. Third intention= When third intention healing is used, the wound is left open for a time to allow granulation tissue to form, then it is sutured closed.

(Fa-Davis quiz assignment) While observing the skin of a patient, the nurse discovers a pressure injury that extends into the subcutaneous tissue with undermining and tunneling. The nurse would report the patient has which stage of pressure injury? 1.Stage 1 2.Stage 2 3.Stage 3 4.Stage 4

3.Stage 3 Other terms to know Stage 1= indicated by erythema of intact skin, generally over a bony prominence, that will not blanch, or turn white, when it is gently touched with a fingertip. Stage 2= pressure injury occurs when there is a partial-thickness loss and exposed dermis. Stage 3= pressure injury is a full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue but not involving muscle or bone. Stage 4=full-thickness skin and tissue loss, only it involves deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone.

(Fa-Davis quiz assignment) The nurse is describing the inflammatory process. In which order should the nurse explain the process? 1There is increased blood flow to the site. 2Capillaries dilate. 3Pain occurs. 4Injury occurs. 5Damaged cells release histamine. 6Edema develops.

4,5,2,1,6,3

(Fa-Davis quiz assignment) The nurse is observing unlicensed assistive personnel (UAP) move a patient in bed. Which action by the UAP would the nurse praise? 1. Slides the patient across the bed 2. Pulls the patient across the bed 3. Drags the patient across the bed 4. Lifts the patient across the bed

4. Lifts the patient across the bed

(Ati modules) A nurse in an outpatient clinic is collecting data from a client who is 7 days postoperative. Which of the following findings should the nurse expe to find at the client's incision site? O Ared incision site with a small amount of exudate A bright pink incision site that is absent of exudate O A pale pink incision site with moderate amounts of exudate INCORRECT OAwhite tb silver incision site absent of exudate

A bright pink incision site that is absent of exudate

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? A client who has a Braden Scale score of 9 O A client who has a Braden Scale score of 23 A client who has a Braden Scale score of 12 O A dient who has a Braden Scale score of 15

A client who has a Braden Scale score of 9

(Ati modules) A nurse is assisting with the care of a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? O A client who is NPO for surgery and is receiving IV fluids. A client who has a lower extremity fracture and uses the overhead bed trapeze to move. A client who is incontinerit and is taking a prescribed diuretic. A client who has lung cancer and will be receiving their first radiation treatment

A client who is incontinerit and is taking a prescribed diuretic.

The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges A. Are approximated. B. Migrate across the incision. C. Appear slightly pink. D. Slightly overlap each other.

A. are approximated

(Ati modules) A nurse is caring for a client who has a heavy drainage from a moist red wound that bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis? Transparent Hydrogel Alginate dry gauze

Alginate

Avulsion

An injury in which soft tissue is torn completely loose or is hanging as a flap.

(Ati modules) A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the nt's pressure injury? Barrier creams Antifungal ointment Chemical debridement agent OArmbiotic agert INCORRECT

Barrier creams

(canvas questions) Which of the following describes a third intention wound closure? A. The wound is clean with little tissue loss. B. There is greater tissue loss and the wound edges are irregular. C. The wound is left open for a time to allow granulation tissue to form, then it is sutured closed. D. The edges are approximated and the wound is sutured closed.

C. The wound is left open for a time to allow granulation tissue to form, then it is sutured closed.

(Ati modules) A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? O Tricyclic antidepressants O Corticosteroids Deta tlockers Aolinergc INCORRECT

Corticosteroids

A nurse is assisting with the care of a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take? O Ask the client to bear down and cough. Ask another nurse to bging icepacks to apply to the wound. Cover the client's wound with a sterile saline dressing O Place the client in high-Fowler's positicon.

Cover the client's wound with a sterile saline dressing

(canvas questions) A surgical wound that bleeds profusely is called a(n): A. Dehiscence B. Evisceration C. infections D. Hemorrhage

D. Hemorrhage

1. A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be A. It has no odor. B. A culture is negative. C. The edges reveal the presence of fluid. D. It shows purulent drainage coming from the incision site.

D. It shows purulent drainage coming from the incision site.

A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be A. It has no odor. B. A culture is negative. C. The edges reveal the presence of fluid. D. It shows purulent drainage coming from the incision site.

D. It shows purulent drainage coming from the incision site.

A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides A. An absorbent surface to collect wound drainage. B. Decreased incidence of skin maceration. C. Protection from the external environment. D. Moisture needed for wound healing.

D. Moisture needed for wound healing.

A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides A. An absorbent surface to collect wound drainage. B. Decreased incidence of skin maceration. C. Protection from the external environment. D. Moisture needed for wound healing.

D. Moisture needed for wound healing.

(Ati modules) A nurse is assisting with the care of a 6-month-old infant who has diarrhea.The nurse should monitor the infant for which of the following alterations in tissue integrity?Premature wrinkling O skin tears O Dermatitis OCellulites

Dermatitis

A nurse is assisting with discharge teaching for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the client's caregiver to prevent further skin breakdown? Fles the cents knees while in bed Do not use pilows to support extremities O Be sure to keep the skin moist rodea fm.matress for the client

Fles the cents knees while in bed

A nurse is collecting data from a client who has a stage 3 pressure injury on the coccyx. Which of the following alterations in tissue integrity should the nurse expect to find? O Partial-thickness skin loss with a pink and moist wound INCORRECT O An area of non-blanchable erythema Full-thickness skin loss with visible adipose tissue O Full-thickness skin loss with visible muscle and bone

Full-thickness skin loss with visible adipose tissue

(Ati modules) A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, of the following types of dressings should the nurse select to help despite administration of the prescribed analgesic prior to wound care. Which minimize the pain of dressing changes? Wet-to-dry O Abdominal pads (ABD) Dry gauze Hydrogel

Hydrogel

A nurse is assisting with the care of a client who has a deep foot wound with minimal exudate and necrotized tissue. Which of the following dressing types should the nurse anticipate a prescription for to cover the wound? O Hydrofiber Alginate INCORRECT Hydrogel O Transparent film

Hydrogel

(Ati modules) A nurse is reinforcing teaching with a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing.Which of the following client statements indicates an understanding of the teaching? O Tshould avoid meat products." O 1 should consume a diet high in carbohydrates." O 1 should include fruit and vegetables with every meal. hould increase my proteln intake

I should increase my proteln intake

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information? "I should expect a small separation along the incision line." INCORRECT O "If I feel like something popped. I should sit up in bed." Ishould report pain at my wound site" "Recurrent vomiting is expected after surgery."

Ishould report pain at my wound site"

A nurse is reinforcing teaching with a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching? ... O "Pressure injury documentation includes the location, stage, measurements, condition of the wound bed and any drainage present." "Dralnage from a pressure injury only needs to be documented if a foul odor is present." INCORRECT "if the pressure injury is healing as expected, documentation can be completed with every other dressing change." O"Pressure injuries found on the mucous membranes should be documented as stage t pressure injuries"

O "Pressure injury documentation includes the location, stage, measurements, condition of the wound bed and any drainage present."

(Ati modules) A nurse planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care? O Leave nonbleeding wounds open to the air O Administer a corticnsteroid medication. O ininate mecharical debnidement O Apply oygen at 2 Lin vianasal cannula a

O Apply oygen at 2 Lin vianasal cannula a

(Ati modules) A nurse is assisting with the care of a client who has a dime-size stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use? O An alginate dressing A wet gauze dressing O Ahydrogel dressing O Atransparent film

O Atransparent film

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take? O obtain the culture using a clean cotton applicator O Clean the wound with 0.9% sodium chloride CORRECT O Collect drainage from the area surrounding the wound. Place the applicator in a dry vial until cultures are complete.

O Clean the wound with 0.9% sodium chloride

A nurse is assisting with the care of a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full.Which of the following actions should the nurse take? Kink the tubing to prevent further drainage. O Place the bulb on a flat surface and measure the amount of drainage. Decrease the drainage suction force. O Empty and measure the drainage.

O Empty and measure the drainage.

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis? O Hypertension O Increased blood glucose O Decreased WBC count O Increased BUN

O Increased blood glucose

(Ati modules) A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive? Placing a transparent dressing over the pressure injury Applying hydrocollolds to the wound bed Pulsating lavage OUsing a topical enzyme solution in the wound bed

O Pulsating lavage

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity? O The AP places the client in high-Fowler's position. shearing client O The AP places pillows under the client's lower extremities. O The AP feeds the client 80% of each meal. O The AP cleans and dries the client's perineum after each episode of incontinence.

O The AP places the client in high-Fowler's position.

(Ati modules) A nurse in a dermatology clinic is assisting with the development of a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster? Collagen and elastin fibers Increase with age O The dermis contains blood vessels that help nourish the epidermis. The skin consists of four distinct layers. The epidermis contains cells that assist in systemic immune responses

O The dermis contains blood vessels that help nourish the epidermis.

A nurse is contributing to the plan of care for an older adult client who is bedridden.Which of the following actions should the nurse include in the adult plan to prevent skin breakdown?O Tilt the client on their side at 30 O Firmly massage lotion into the client's skin. O Slide the client to the edge of the bed to transfer, O Keep the head of the bed at 45 when in the supine position.

O Tilt the client on their side at 30

(Ati modules) A nurse is reinforcing teaching with a client about staple removal. Which of the following statements should the nurse make? "Your staples will dissolve in about 4 weeks." You will need to be placed under general anesthesia for the staples to be removed." O "Staples are unlikely to become embedded in the skin making removal simple O Your staples will be removed in about 2 weeks. CORRECT

O Your staples will be removed in about 2 weeks.

Blunt injuries

RTA Falls assault sport inuries bite injuries an injury to the body caused by forceful impact, injury, or physical attack with a dull object or surface

(Ati modules) A nurse is documenting data about a healing wound on a client's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document which of the following types of wound drainage? Serosanguineous Sanguineous Serous Puruient

Serosanguineous

(Ati modules) A nurse is documenting data about a deep necrotic wound on a client's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document? O Keloid Slough Granulation O Eschar

Slough

(Ati modules) A nurse is staging a pressure injury over a client's right heel area. The pressure injury has no eschar or slough and no exposed muscle nurse should identify that this pressure injury is classified as which of the following? A suspected deep tissue injury Stage 3 stage 4

Stage 3

(Fa-Davis quiz assignment) Question 13. The nurse has to obtain a wound culture from a patient's draining wound. Which action should the nurse take? 1. Swab the outer edges of the wound. 2. Swab the dark black area of the wound. 3. Swab the area of drainage in the wound. 4. Swab the pinkish, red area of the wound.

Swab the pinkish, red area of the wound. Other terms= *Avoid touching the cotton tip to the outer edges of the wound because normal flora (microorganisms that live on the patient's skin) can contaminate the culture. *Do not swab areas where slough or eschar (black, leathery tissue) is present. *Do not swab in a pool of exudate because the culture will not reflect microorganisms only present in the wound.

A nurse is reinforcing teaching with a newly licensed nurse about the functions of the skin. Which of the following statements by the newl licensed nurse indicates an understanding of the teaching? O The epidermis pads intermal organs and structures." The skin assists in the regulation of body temperature. The subcutaneous layer of the skin contains cells that contribute to skin and hair color." The skin is strongest during early childhood."

The skin assists in the regulation of body temperature.

Hematoma

collection of blood outside of a blood vessel, It occurs because the wall of a blood vessel wall, artery, vein , or capillary has been damage-causing leakage *these are close wounds, this fluid will clot within minutes or hours, then after a few days will liquefy and thus increasing risk for a secondary infection that leads to pus formation

Types of wounds

partial thickness and full thickness

12. After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as: a) Stage I b) Stage II c) Stage III d) Stage IV

stage II

surgical wounds

wounds caused by a surgical procedure