Wound Care PrepU

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 takes approximately 2 weeks for the edges to appear approximated and heal together -a wound with increased swelling and drainage that may occur during the first 5 days of wound healing -a wound that does not feel hot and tender upon palpation -a wound that forms exudate due to the inflammatory response incisional pain during the wound healing, which is most severe for the -first 3 to 5 days, and then progressively diminishes

-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 Explanation: The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. This would be a correct way to document a normally healing wound. A wound that does not feel hot upon palpation would be another example of correctly documenting a wound that has no complications. A wound that is warm to touch is not an abnormal finding. A wound that forms exudate due to the inflammatory response would be correct documentation of a normal finding.

Which best describes the proliferative phase, the third phase of the wound healing process? -the onset of vasoconstriction, platelet aggregation, and clot formation -marked by vasodilation and phagocytosis as the body works to clean the wound -reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization -decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound

-reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization Explanation: In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing, hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands? "I will check and empty the drain every 6 hours." "I will squeeze the chamber and apply the cap to maintain negative pressure." "I will apply a dressing at the end of the drain to catch any drainage." "I will alternate between positive and negative pressure every 2 hours."

"I will squeeze the chamber and apply the cap to maintain negative pressure." Explanation: The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain has gauze at the end of the drain to catch drainage.

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? Acute pain Knowledge deficit Disturbed body image Impaired tissue integrity

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 client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? Jackson-Pratt drain Penrose drain Hemovac drain Wound pouching

Penrose drain Explanation: Penrose drains are commonly used after a surgical procedure or to drain an abscess. Jackson-Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is typically placed into a vascular cavity where blood drainage is expected after surgery, and wound pouching is used on wounds that have excessive drainage.

Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan? -To facilitate adequate rest, disconnect NPWT each night between 2200 and 0700. -Record the quantity of drainage once per shift and document on the intake and output record. -Change the wound dressing daily, or more frequently if excessive output is noted. -Remove the transparent dressing if a leak is noted

Record the quantity of drainage once per shift and document on the intake and output record. Explanation: Output from NPWT should be recorded once per shift. Leaks can often be resolved by reinforcing the dressing and the treatment should continue 24 hrs/day. Dressings are normally changed two to three times per week.

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? -Reduce the time interval between dressing changes. -Assure that the packing material is completely saturated when placed in the wound. -Use less packing material. -Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.

Reduce the time interval between dressing changes. Explanation: Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

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 newborn a client with cardiovascular disease an older client with arthritis 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: an allergic reaction to medications. an allergic reaction to detergent. a rash related to a yeast infection. 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.

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? puncture laceration contusion avulsion

avulsion Explanation: An avulsion involves the stripping away of large areas of tissue, leaving cartilage and bone exposed. Therefore the nurse will document this assessment finding as an avulsion. A puncture is an opening of the skin caused by a narrow, sharp, pointed object. A laceration is the separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore the nurse would not document the finding as a puncture, laceration, or contusion.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care? -cleanse the wound from the outer area toward the inner area -cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing -cleanse the wound in parallel strokes from the top to the bottom of the wound -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 of 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.

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? transparent film hydrocolloid dressing hydrogel alginate

hydrocolloid dressing 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.

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? autolytic debridement biosurgical debridement enzymatic debridement mechanical debridement

mechanical debridement Explanation: Mechanical debridement involves physical removal of 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.

A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? primary intention secondary intention tertiary intention desiccation

secondary intention Explanation: The client with 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 in which cells are dehydrated. This leads to cell death and delays healing.

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: to provide a sinus tract for drainage. to provide drainage for bile. to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity.

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.

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? gauze adhesive strips with eyelets transparent hydrocolloid

transparent Explanation: Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist.

An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor? -The client's size limits his activity level. -Adipose tissue is poorly vascularized. -Obesity is linked to impaired white blood cell function. -The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.

Adipose tissue is poorly vascularized. Explanation: Wound healing may be decreased in obese clients. Because adipose tissue is relatively avascular, it provides only a weak defense against microbial invasion and impairs delivery of nutrients to the wound.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? Apply a skin protectant to the skin around the incision. Apply a skin protectant to the incision site. Apply a sterile gauze sponge over the incision site. Apply a transparent dressing over the incision site.

Apply a skin protectant to the skin around the incision. Explanation: Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied.