Wound Care PrepU

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."

The nurse will be providing health education and demonstration for a client with a wound. Put the steps in order of which the nurse would perform the wound assessment. All options must be used.

1. Assess the client's readiness to learn. 2. Teach regarding the normal healing process. 3. Teach regarding the signs and symptoms they should report. 4. Use teaching aids to help with client's learning. 5. Explain the importance of adequate nutrition and fluid intake in wound healing. 6. Have the client teach back information about skin care.

A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider?

Alginate

The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as:

Exudate containing white blood cells, protein, and tissue debris

Which type of burn injury requires skin grafting?

Full-thickness

The nurse is caring for a client with a skin lesion that is oozing. The surrounding skin is acutely inflamed. What type of dressing should the nurse apply?

Interactive

While the nurse is performing a skin assessment on a dark-skinned client, the nurse notes that the client has a healed wound on the leg but that the wound has an excess of scar tissue. The nurse documents this as:

Keloid

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?

Place an ice pack

An 8-year-old child requires wet dressings four times a day as treatment for a skin disorder. What would be most important for the nurse to do?

Premedicate the child before changing the dressing.

Which type of healing occurs when the edges are not approximated and the wound fills with granulation tissue?

Second intention

A client has a burn that involves the entire epidermis and various degrees of the dermis. It is painful, moist, and blistered. The nurse recognizes the burn as:

Second-degree partial thickness

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

Stage II

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage II pressure ulcer

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

The client has fistula formation

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Wound dehiscence

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?

at the base of the wound

A term used to describe a partial or complete separation of wound edges is

dehiscence.

The nurse is assessing a client for acute inflammation of a wound. Which symptom does the nurse attribute to the acute inflammatory response?

edema

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?

elevating and supporting the stump

The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage?

figure-of-eight turn

Which client would likely benefit the most from hyperbaric oxygen therapy?

trauma client who developed Clostridium spp., an anaerobic bacterial infection in the femur

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse?

"If a wound heals on the surface but infection remains, it will open and drain."

The process of clot retraction squeezes serum from the clot, thereby joining the edges of the broken vessel. Through the action of actin and myosin, filaments in platelets contribute to clot retraction. Failure of clot retraction is indicative of:

A low platelet count

A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment, the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist (ET). When gathering supplies for a stage II ulcer, what characteristics would the ET anticipate? Select all that apply.

The ulcer is superficial, like a blister. Partial-thickness skin loss of the epidermis is evident.

A client with diabetes mellitus has a foot ulcer. The physician orders bed rest, a wet-to-damp dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client?

They debride the wound and promote healing by secondary intention.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply.

This is a severe burn and nerve endings have been destroyed. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary.

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?

Homografts

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

Superficial

A client has been diagnosed with an abscess. Upon assessment of the client, the nurse would expect to find:

a localized pocket of infection composed of devitalized tissue, microorganisms, and the host's phagocytic white blood cells.

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 wound of a postoperative client. The client has a 6-inch abdominal wound that is well approximated and closed with surgical suture. The wound does not display any redness or drainage. The nurse would document the healing process as:

Primary intention

The nurse applies a moisture-retentive dressing to a patient's wound. She understands that the main advantage of this dressing, rather than a wet dressing, is its ability to:

Provide autolytic debridement.

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?

Stage III

A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the incision is separating. What is the nurse's priority action?

Stop the staple removal, cover the incision, and report the findings to the physician.

When caring for a client with a wound that is healing by primary intention, the nurse recognizes which characterization best describes this type of wound?

Surgical incision

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?

The client rinses around the clean incision site, using gauze squares moistened with normal saline.

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply.

The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot and tender upon palpation a wound that forms exudate due to the inflammatory response

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?

Using normal saline solution to clean the ulcer and applying a protective dressing as necessary

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

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply?

moist sterile saline gauze

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

using sterile technique during the dressing change

The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse would document this drainage?

clear, watery, yellow-tinged drainage