Chap 48 EAQ's review Skin wound care

Stage 1 pressure ulcer

intact skin with nonblanchable redness

Slough

lighter in color, thinner and stringy in consistency; color can be yellow, gray, with, green, brown

Dorsal

located near

orthostatic hypotension

low blood pressure that occurs upon standing up

Granulation tissue

new, healthy tissue produced to fill in a wound

Which processes occur in the proliferative phase of wound healing?

no- Activation of the coagulation cascade Activation of the coagulation cascade occurs in the inflammatory phase, not in the proliferative phase . Correct Stimulation of angiogenesis Stimulation of angiogenesis occurs in the proliferative phase to provide the new tissue with oxygen and nutrients. Correct Creation of granulation tissue Creation of granulation tissue occurs in the proliferative phase to fill in the wound with new cells. no- Strengthening of scar tissue Strengthening of scar tissue occurs in the maturation/remodeling phase, not in the proliferative phase. Incorrect no- Achievement of 80% of tensile strength Achievement of 80% of tensile strength occurs in the maturation/remodeling phase, not in the proliferative phase.

Which classic signs would the nurse observe in a wound that is in the inflammatory phase of healing?

no- Coolness Warmth, not coolness, would occur in the inflammatory phase. Correct Swelling Swelling would occur in the inflammatory phase. Correct Erythema Erythema is a classic sign that occurs in the inflammatory phase of wound healing. Incorrect no - No pain There would be pain during the inflammatory phase of wound healing. no- Paleness Redness, not paleness, would occur in the inflammatory phase.

Which factor that affects skin integrity is depicted in this image?

no- Friction Friction would be caused by rubbing the skin against something, not just by lying supine. no- Shear Shear would be indicated by an image of a person sitting and sliding down or stretching and by the compression of blood vessels due to gravity and friction, not just by a person lying supine. no - Moisture This image does not depict moisture; the image depicts pressure points on bony prominences in the supine position. Correct Prolonged pressure Prolonged pressure can damage bony prominences and pressure areas on the body, which are depicted in this image.

Match the wound bed condition to its cues. 1. Pale, soft, wrinkled 2. Beefy red, shiny, moist 3. Black, hard, dry 4. Purulent yellow

Answer: 1. macerated 2. granulated 3. necrotic 4. infected

Loosely adherent

pulls away from wound, but attached to wound base

How to describe an odor?

strong, foul, pungent, fecal, musty, sweet

orthostatic hypertension

sudden increase in blood pressure when a person stands up

Secondary intention

the wound must heal from the bottom and sides, filling in with new tissue

Match the type of wound drainage to the color of fluid the nurse would observe on a patient's dressing. 1. clear and watery 2. pink to pale red 3. bright red 4. greenish, yellow

Answer: 1. serous 2. serosanguineous 3. sanguineous 4. purulent

A child has been exposed to freezing temperatures as part of multiple trauma. The nurse observes that the child's lips, hands, and feet are cyanotic. The nurse attributes the discoloration to which skin function?

Heat regulation.

Which action for skin hygiene would the nurse take for an obese patient who is immobile?

Keep skin folds dry from perspiration

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. 1. Patient who just had an incision eviscerate 2. Patient who is experiencing shock from a profusely bleeding wound 3. Patient with a stage 4 pressure injury

Answer: 2. 1. 3.

An undernourished, low weight adolescent with cerebral palsy is admitted to the PICU. His skin is intact and he requires mechanical ventilation. What should skin care interventions focus on preventing?

Pressure ulcers due to decreased subcutaneous tissues.

The student nurse is discussing skin integrity with a patient who has a closed wound. Which statement made by the student nurse indicates teaching has been effective? "A closed wound indicates that your skin is not intact." "A closed wound indicates you have a benign condition." "A closed wound indicates an actual break in the skin's surface." "A closed wound indicates that underlying tissue damage may still exist."

"A closed wound indicates that underlying tissue damage may still exist."

A nurse educator has just finished teaching a lesson about types of wound dressing. Which student statement about alginate dressings indicates understanding of the lesson? "Alginate dressings are adhesive." "Alginate dressings are occlusive." "Alginate dressings add moisture to wounds." "Alginate dressings are produced from brown seaweed."

"Alginate dressings are produced from brown seaweed."

A patient who was recently diagnosed with diabetes mellitus asks the student nurse why diabetes mellitus affects skin integrity and healing. Which response by the student nurse indicates effective learning? "Diabetes mellitus causes changes to the nervous system." "Diabetes mellitus causes changes to the digestive system." "Diabetes mellitus causes changes to the pulmonary system." "Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems."

"Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems." Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems, which decreases blood flow to the wound. Decreased blood flow decreases the supply of nutrients and oxygen to the wound, thereby affecting skin healing.

Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound?

"My wound will look beefy red within 1 week."

A nurse is teaching a student nurse about the dermis. Which statement shows education has been effective?

"Sebaceous glands are located in the dermis."

A nurse is teaching a student nurse about the dermis. Which statement shows education has been effective? "The dermis is comprised of dead skin cells." "Sebaceous glands are located in the dermis." "Rete ridges allow the dermis and epidermis to slide." "The dermis is the same thickness everywhere on the body."

"Sebaceous glands are located in the dermis."

A child has several scalp lacerations following a bicycle accident. The mother is distraught from what seems to be profuse bleeding. The emergency department nurse should explain which of the following to the mother to help her understand the injuries?

"The skin has a very good blood supply, so cuts like this do bleed a lot."

A nurse is teaching a student nurse about the layers of the epidermis. Which statement shows a need for further teaching?

"The stratum lucidum is the outer layer of the epidermis."

The nurse is caring for a patient with a contaminated wound that was initially left open for a while after surgery. What is the most appropriate explanation of tertiary intention that the nurse makes to the patient? "The wound will be closed later when the infection risk is reduced." "The wound does not need to be closed if it was initially left open." "The wound will be left open for observation and not closed at all." "The wound is being observed for drainage because of the cause of the surgery."

"The wound will be closed later when the infection risk is reduced."

The registered nurse is teaching the student nurse about delayed wound healing. Which statement made by the student nurse indicates a need for further teaching? "Wounds are at risk for infection by some types of drugs, such as steroids." "Wounds should be kept wet and moist to prevent skin tissue from tightening." "Wounds may have a delayed healing time caused by nutritional deficiencies." "Wounds are made worse by external forces against the skin, such as pressure or friction."

"Wounds should be kept wet and moist to prevent skin tissue from tightening."

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.

- Patient who is experiencing shock from a profusely bleeding wound - Patient who just had an incision eviscerate - Patient with a stage 4 pressure injury

A nurse is teaching a student nurse about the subcutaneous layer of skin. Which statements by the student nurse shows effective teaching?

-"The subcutaneous provides insulation to protect against heat and cold." -"The subcutaneous provides cushioning for bony prominences and protection of internal organs."

An 80-year-old patient's skin is assessed to be fragile, thin, dry, wrinkled and transparent. What are these findings related to?

-Loss of elastin. -A decrease in the number of epithelial cells. -A flattening of the layer of skin under the epidermis.

What is embedded in the dermis?

-Nerves. -Lymphatics. -Sweat glands. -Hair and nail follicles.

Which are functions of the skin?

-Normalizes body temperature. -Transmits sensations of pain. -Forms an effective barrier against environmental hazards. -Assists with the elimination of toxins and wastes from the body.

Which are functions of the basale layer of the epidermis?

-Provides skin coloring and protects it from ultraviolet light. -Produces new cells that push through to the stratum corneum. -Gives the skin strength and flexibility and allows it to repair itself.

Which Braden Scale score range would alert the nurse that a patient is at moderate risk for pressure injury development? Record your answer as whole numbers separated by a hyphen. __

13-14 - If the patient is at moderate risk for pressure injury development, the Braden score will be 13‐14.

What amount of zinc is recommended for wound healing? 15-30 mg 30-50 mg 25-60 mg 50-70 mg

15-30 mg

Using military time, at what time would the nurse turn the patient if the patient was last turned at 1 p.m.?

1500

Using military time, at what time would the nurse turn the patient if the patient was last turned at 1 p.m.? Record your answer as a whole number.

1500 - The patient is turned every 2 hours. If the patient was turned at 1 p.m. (1300 military time), the patient would be turned at 1500.

What amount of retinol equivalents for vitamin A per day should the nurse recommend a patient to consume to support proper wound healing? 1200-1400 1400-1500 1500-1600 1600-2000

1600-2000

According to the Braden scale, a score lower than________ places a person at risk for pressure sore development.

18

How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing? 15-20 kcal 20-25 kcal 25-30 kcal 30-35 kcal

30-35 kcal

What amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing? 15-20 mL 20-25 mL 25-30 mL 30-35 mL

30-35 mL

An adult male patient presents to the ER, suffering from a traumatic brain injury after having been in a bad car accident. He is unconscious, incontinent of both urine and stool. According to the Norton Scale, the nurse realizes this places him at great risk for skin breakdown. What is this patient's Norton Scale score? 10 8 5 20

5

The skin weighs more than

6 pounds.

Which patient situations would prompt the nurse to question a prescription for heat therapy?

A patient with a local tooth abscess A patient with possible appendicitis A patient with bleeding from a small wound

What is a fistula? Muscular layer of tissue that forms after wound healing. Connection of blood vessels that form after an incision heals. Connection between two areas of the body by the nervous system. Abnormal connection between two internal organs or between protruding internal organ and the outside of the body.

Abnormal connection between two internal organs or between protruding internal organ and the outside of the body. A fistula is an abnormal connection between two internal organs or between protruding internal organ and the outside of the body.

Which cleaners harm cells and can delay healing? Select all that apply. Acetic acid Dakin's solution Povidone-iodine Hydrogen peroxide Normal saline 0.9%

Acetic acid Dakin's solution Povidone-iodine Hydrogen peroxide

The nurse is providing care to a patient with a pressure ulcer that is covered in eschar. Which dressing prescription will the nurse use for this patient? None Adherent film Composite film Calcium alginate

Adherent film A pressure ulcer covered in eschar is an unstageable pressure ulcer. The nurse would use an adherent film dressing because it will facilitate softening of the eschar to allow for debridement. No dressing is appropriate for an intact stage I pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer. A calcium alginate dressing is appropriate for a clean stage III or stage IV pressure ulcer.

A patient has a 3 cm × 3 cm × 0.5 cm pressure ulcer to his coccyx through all layers of the epidermis with the dermis exposed. What will be a priority of care for this patient?

Administration of an analgesic.

A nurse is caring for pediatric patient with a bleeding, infected thoracic gunshot wound. What dressing combination is best for the nurse to apply? Alginate and foam Transparent and gel Hydrocolloid and foam Hydrocolloid and gauze

Alginate and foam

A nurse is teaching a group of older adults about skincare. A student asks the nurse what causes freckles? What would be an accurate response? An overproduction of collagen A stiffening of the epidermal tissue An uneven distribution of melanin Weakened blood vessels in the skin

An uneven distribution of melanin

A nurse is teaching a group of older adults about skincare. A student asks the nurse what causes freckles? What would be an accurate response?

An uneven distribution of melanin.

Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with minimal drainage? A. Foam B. Alginate C. Gauze D. Transparent

Answer D: - The nurse would anticipate caring for transparent dressings, which are appropriate for wounds with minimal or no drainage.

Match the unexpected skin assessment finding to its description. 1. Blue Skin 2. Pinpoint, flat, red spots 3. Red skin 4. Bruise

Answer: 1. cyanosis 2. petechiae 3. erythema 4. ecchymosis

Which term would the nurse use to describe excessive moisture on the patient's skin? A. Diaphoresis B. Ashen C. Purpura D. Icterus

Answer: A

Which interpretation would the nurse make about a patient's wound culture that is positive? A. It is infected. B. It is hemorrhaging. C. It is eviscerated. D. It is nonhealing.

Answer: A - A positive wound culture indicates the patient's wound is infected.

Which patient is likely at risk for developing a pressure injury? A. Patient with unrelieved pressure who has a fractured hip B. Patient with a history of sports-related injuries and concussions C. Left-handed patient with a broken left wrist D. Paralyzed patient who is being turned and repositioned every 2 hours

Answer: A - The patient with unrelieved pressure is most at risk for developing a pressure injury, because tissue ischemia can form and lead to pressure injuries.

Which action by the nurse is priority when providing discharge teaching to a patient and spouse about wound care when the spouse is the primary caregiver? A. Provide written instructions B. Have the patient perform a return demonstration. C. Offer strategies on how to promote wound healing D. Determine the patient's coping abilities.

Answer: A - The priority is to provide written instructions for the spouse because the spouse is the primary caregiver and will need reinforcement of learning at home.

Which hypothesis would the nurse develop for an immobile patient who has intact skin? A. Risk for Impaired Skin Integrity B. Traumatic Wound C. Risk for Impaired Tissue Integrity D. Pressure Ulcer/Injury

Answer: A Because the patient is immobile but still has intact skin, the hypothesis is a Risk for Impaired Skin Integrity.

Which action would the nurse take when placing noncommercial ice packs on a patient's injured shoulder?

Remove air from the pack before closing.

Which foods would the nurse recommend for a patient with a leg wound who needs to increase vitamin A intake? A. Carrots B. Sweet Potatoes C. Strawberries D. Cheese E. Milk

Answer: A, B - Both high in vitamin A

Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage? A. Notify the primary health care provider. B. Take the patient's temperature. C. Review white blood cell count. D. Chart the expected findings. E. Apply Steri-Strips to the wound.

Answer: A, B, C - The nurse would notify the primary health care provider because the wound is infected. - The nurse would take the patient's temperature because the patient's wound is infected. - The nurse would review the patient's white blood cell count because the patient's wound is infected.

Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity? A. Bone B. Tendon C. Muscle D. Dermis E. Epidermis

Answer: A, B, C Bone, Tendon, & Muscle would all be damaged

Which steps would the nurse take to measure the dimensions of a sacral pressure injury? A. Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. B. Measure the width laterally from left to right at the widest portion of the wound. C. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. D. Measure the length vertically from the top to the bottom at the widest open area of the wound. E. Measure the width laterally by using a clean cotton-tipped applicator at the largest portion of the wound from left to right.

Answer: A, B, C, D

Which parameters would the nurse monitor after applying a wrap to an ankle? A. Pain B. Pallor C. Paralysis D. Petechia E. Paresthesia F. Pulelessness

Answer: A, B, C, E, F

Which cues related to skin integrity may reflect an overall health problem? A. Cracking B. Tenting C. Warm skin temperature D. Pathogens identified in a wound culture E. Immunocompetence

Answer: A, B, D

Which cues would the nurse observe for a patient with an infected lateral malleolus wound? A. Erythema noted on the superior portion of the wound B. Purulent, malodorous drainage C. 1.5-cm wound with serous drainage and tissue epithelialization D. Temperature of 102°F (38.9°C) E. Pain level of 2/10

Answer: A, B, D

Which factors may impact the development of pressure injuries or nonhealing wounds? A. smoking B. Diabetes C. Specific gender D. Urinary Incontinence E. Skin tone

Answer: A, B, D

Which patient situations are of immediate concern? A. A patient is experiencing shock. B. A patient is profusely bleeding from a wound. C. A patient has an infected wound. D. A patient has an eviscerated wound. E. A patient has a stage 4 pressure injury.

Answer: A, B, D

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum? A. Wound, ostomy, and continence nurse (WOCN) B. Social Work C. Surgeon D. Nutritionist E. X-Ray Technician

Answer: A, B, D - A WOCN would be consulted in this situation to ensure proper healing of the pressure injury. -A social worker would be part of the collaboration team in this situation to ensure the homeless patient has access to community resources and finances. -A nutritionist should be consulted because the patient is thin.

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident? A. Patient's pressure injury will decrease at least 1 to 2 cm in size per week. B. Patient's wound will exhibit granulation tissue in the wound by 1 week. C. Patient will demonstrate wound care after receiving teaching. D. Patient will have intact skin throughout hospital stay.

Answer: B A break in the skin from external forces, such as trauma or an accident, indicates a wound; thus, this goal would directly relate to the break in skin from external forces.

Which techniques would the nurse use to troubleshoot issues with patients' dressings? A. Use an abdominal binder to help a patient who has an abdominal wound to cough. B. Use Montgomery straps for a patient who needs frequent dressing changes. C. Use hydrogen peroxide to remove residue left on the patient's skin from a dressing. D. Use a splint to help a patient who has an abdominal incision to deep breathe. E. Use acetone to help remove a dressing stuck to the patient's skin.

Answer: A, B, D - An abdominal binder helps secure dressings and drains and provides support when coughing and would be implemented by the nurse. - Montgomery straps are used for frequent dressing changes to protect the skin from irritation and skin tears; the straps would be used by the nurse. - A splint helps provide support to a patient's incision when deep breathing; it would be used by the nurse.

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity? A. Low prealbumin levels B. Immobility C. Inexperience with wound care D. Stage 2 pressure injury E. Stage 4 pressure injury

Answer: A, B, D -Low prealbumin level is a cue for Impaired Skin Integrity because it can affect healing. -Immobility is a cue for Impaired Skin Integrity because it can lead to prolonged pressure. -A stage 2 pressure injury is a cue for Impaired Skin Integrity because it affects the epidermal and dermal layers of the skin.

Which factors can place a patient at risk for a pale, dry wound? A. anemia B. Diabetes C. wound infection D. vascular disease E. Nutritional deficiencies

Answer: A, B, D, E

For which patient hypotheses would the nurse select turning and positioning as a solution? A. impaired Skin Integrity B. Risk for Pressure Ulcer/Injury C. Malignant Wound D. Impaired Tissue Integrity E. Risk for Impaired Skin Integrity

Answer: A, B, D, E - All solutions for Impaired Skin Integrity.

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days? A. Therapies consistent with guidelines for treatment of wounds B. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) C. Ability of the patient to maintain a pain rating of 8/10 during activities of daily living D. Agreement of the patient with the treatment plan E. Capability of the patient to purchase supplies for home care as required

Answer: A, B, D, E - Therapies consistent with guidelines for treatment of wounds and pressure injuries are an appropriate component to include. - Recommendations from collaborating health care professionals, such as a WOCN, are appropriate components to include. - The patient should agree with the established treatment plan to encourage compliance, and this agreement would be included. - Capability of the patient to purchase supplies for home care is an appropriate component of care to include.

Which actions would the nurse take for a comatose patient who has frequent liquid stools and has a Braden Scale score of 8? A. Turn the patient every 2 hours for repositioning. B. Apply cold compresses to bony prominences. C. Pad and protect any bony prominences. D. Wash and dry the patient's skin after each liquid stool. E. Apply an abdominal binder for support. F. Replace soiled linens.

Answer: A, C, D, F - Turning and repositioning the patient from side to side helps prevent pressure on the skin, so the nurse would implement this action. - Padding and protecting any bony prominences help avoid pressure on the skin; the nurse would pad and protect bony prominences to avoid pressure injuries. - Washing and drying the patient's skin helps keep the skin clean and dry, so the nurse would implement these actions. Moisture and body fluids irritate the skin and cause excoriation. - Replacing soiled linens helps keep the skin clean and dry; thus, the nurse would implement this action. Prolonged contact with moisture and enzymes can lead to excoriation and maceration.

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound? A. Repositioning the patient B. Administering medication for wound pain C. Assessing and evaluating a patient's skin and wounds D. Reporting any changes in patient's skin integrity or condition. E. Applying a nonsterile dressing for chronic wounds with an established treatment plan

Answer: A, D, E -Repositioning the patient is a task the UAP can perform for a patient with a wound. -The UAP can report any changes in the patient's skin condition or integrity to the nurse. -Applying a nonsterile dressing for chronic wounds with an established treatment plan

Which action for skin hygiene would the nurse take for an obese patient who is immobile? A. Bathe using hot water B. Use antibacterial soap. C. Apply moisture barrier to buttocks. D. Keep skinfolds dry from perspiration.

Answer: D - The nurse would keep the skinfolds dry. In an obese patient the skinfolds must be kept dry from perspiration to prevent skin breakdown.

Which evaluative cue would alert the nurse that a patient with a pressure injury is declining? A. Wound diameter was 5 cm but is now 4 cm. B. Braden Scale score was a 9 but is now an 8. C. Transfer assistance was with two people but is now with one person. D. Dietary consumption was 50% but is now 75%.

Answer: B - A Braden Scale score that decreases indicates the patient is declining. The lower the score, the higher the risk for pressure injuries.

Which reasoning explains why a nurse measures wound size during an initial wound assessment? A. To determine the proper medication amount for the wound B. To help assess progression of wound healing C. To provide evidence for the presence of infection D. To reassure patients they are receiving proper care

Answer: B - Measuring wound size helps assess the progression of wound healing. As the wound heals, it becomes smaller.

Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of wound drainage? A. Gel B. Foam C. Transparent D. Hydrocolloid

Answer: B - The nurse would anticipate using a foam dressing. It is indicated for moderately to highly exudative wounds because it pulls fluid away from the wound while maintaining a moist environment.

Which action would the nurse take when placing noncommercial ice packs on a patient's injured shoulder? A. Position the pack directly on the shoulder. B. Remove air from the pack before closing. C. Fill the pack completely with crushed ice. D. Leave the pack in place for 45 minutes.

Answer: B - The nurse would remove the air from the pack before closing.

Which action would the nurse take when caring for a patient's Jackson-Pratt drain? A. Clean toward the drain, inward. B. Reactivate the drain after emptying. C. Wipe the port with acetone wipes. D. Allow the drain to work by gravity.

Answer: B - The nurse would reactivate the drain after emptying. The Jackson-Pratt drain works by suction and must be reactivated or recompressed after emptying.

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound? A. Patient will be infection-free. B. Patient will eat a high-protein diet at every meal. C. Patient will help with transfers within 24 hours. D. Patient's wound will heal normally. E. Patient's incision will have proper healing.

Answer: B, C A SMART outcome is specific, measurable, achievable, and relevant (high-protein diet). It also must have a time frame (at every meal).

Which patient situations would prompt the nurse to question a prescription for heat therapy? A. A patient with morning stiffness B. A patient with a local tooth abscess C. A patient with possible appendicitis D. A patient with bleeding from a small wound E. A patient with edema in the left arm

Answer: B, C, D - The nurse would question this prescription. Heat therapy is not used with abscesses, as it may cause the abscess to rupture. - The nurse would question this prescription. Heat therapy is not used with possible appendicitis, as it may cause the appendix to rupture. - The nurse would question this prescription. Heat therapy is not used with active bleeding, as it increases bleeding.

Which statements by the nurse caring for a postoperative patient who suffered a spinal cord injury indicate correct understanding about assessment tools? A. "I can use the Braden Scale to assess for the risk for infection." B. "The Norton Scale is used to assess for pressure injury risk." C. "I can use the Braden Scale to assess my patient's surgical incision." D. "When assessing for open wounds, I can use the Wound Characteristic Instrument." E. "The Pressure Ulcer Scale for Healing tool is used to track wound healing."

Answer: B, D - The Norton Scale is a tool used to assess risk for developing pressure injuries, and it indicates a correct understanding about assessment tools. - Wound Characteristic Instrument is a tool used to assess open wounds and to track wound healing.

Which actions would the nurse take for a patient receiving heat therapy? A. Allow a patient who must remain flat to take a sitz bath. B. Obtain distilled water for aquathermia treatments. C. Permit the patient to lie on the heating device. D. Check on the disoriented patient more frequently. E. Cover the container and hand when providing warm hand soaks. F. Warm the compress in the microwave.

Answer: B, D, E - The nurse would obtain distilled water for aquathermia treatments because this is the recommended action. - The nurse must check on disoriented patients more frequently because disoriented patients cannot report changes. - The nurse would cover the container and hand to help maintain the temperature of the solution.

Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)? A. Replace dressing every 5 days. B. Monitor for granulation tissue in the wound. C. Angle the canister at least 45 degrees or more. D. Avoid using NPWT for a patient with a cancerous wound. E. If the patient reports pain, change from the black foam to white foam. F. Report to the health care provider if there is an increase in wound drainage.

Answer: B, D, E, F

Which type of fluid would the nurse likely observe if the patient was hemorrhaging? A. serous B. Serosanguineous C. Sanguineous D. Purulent

Answer: C - Sanguineous fluid is bright red, and it indicates bleeding that is observed in hemorrhaging.

Which action would the nurse take for a mother who calls the clinic reporting that a thick yellowish drainage is leaking out of her daughter's surgical leg incision and the incision edges are red and warm? A. Instruct the patient's mother to change the bandage more frequently. B. Suggest the patient elevate her leg and apply an ice bag to the affected area. C. Ask the mother to bring her daughter to the office to be evaluated by the surgeon immediately. D. Suggest that the mother check her daughter's temperature every 4 hours for the rest of the day.

Answer: C - Suggesting that the patient come into the office to be evaluated by the surgeon immediately is the action to take because the scenario indicates the wound is likely infected.

Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement? A. Sharp B. Biologic C. Autolytic D. Mechanical

Answer: C - The nurse is monitoring autolytic debridement, the slowest type of wound debridement, in which the body uses its own enzymes and phagocytic cells for healing.

After receiving report, the nurse would delegate which tasks to the unlicensed assistive personnel? A. Irrigating an arm wound on a stable patient B. Setting up the negative-pressure wound therapy for a patient with a wound C. Turning a patient with a pressure injury D. Teaching the patient about cold pack use at home E. Cleaning an incontinent patient of stool and urine

Answer: C, E

Which assessment technique indicates the nurse properly determined if the patient's incision is healing or is becoming infected? A. Asking the patient health history questions B. Charting the incision line's color and tenderness C. Removing all sutures and/or staples around the wound D. Palpating the area of induration around the incision line

Answer: D - Palpating the area of induration is an effective way to assess if an incision is healing or becoming infected; an infected incision will have induration (hardness) around the incision.

After receiving report, the nurse would delegate which tasks to the unlicensed assistive personnel?

Turning a patient with a pressure injury Cleaning an incontinent patients fo stool and urine

Which action would the nurse take when irrigating a patient's abdominal wound? A. Cool the irrigation fluid. B. Obtain a bulb syringe C. Gently rub the area dry. D. Use sterile technique

Answer: D - The nurse would use sterile technique to irrigate a wound to decrease the chance of infection.

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat? A. Ingest 25% of each meal during hospitalization. B. Report that pain management regimen lowers pain level to 6/10 or lower within the shift. C. Show acceptance of the change in body image by continuing to have the nurse change the dressing after 1. week. D. Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

Answer: D Because the overall outcome is healing of the wound, this outcome demonstrates progressive healing of wound.

Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound? A. "My participation is not needed for position changes." B. "I will be infection-free by the time I go home." C. "I will need to meet with the mental health professional before discharge." D. "My wound will look beefy red within 1 week."

Answer: D If the wound looks beefy red within 1 week, that indicates granulation tissue is forming and the wound is healing, which is normal. This statement indicates successful teaching.

A nurse is caring for an under-nourished 16-month-old who is immobile and has a critical respiratory infection. Which intervention related to skin hygiene is appropriate for the patient? Bathe with hot water and soap. Apply moisture barrier to buttocks. Protect skin from contact with blood. Keep skin folds dry from perspiration.

Apply moisture barrier to buttocks.

Which action would the nurse take for a mother who calls the clinic reporting that a thick yellowish drainage is leaking out of her daughter's surgical leg incision and the incision edges are red and warm?

Ask the mother to bring her daughter to the office to be evaluated by the surgeon immediately.

The nurse is caring for a patients who is on heparin for prevention of deep vein thrombosis related to immobility. What priority assessment will the nurse complete related to this information?

Assess for abnormal bruising, bloody stools, or pallor

A nurse is caring for a patient with a continually draining surgical wound. Which interventions should the nurse perform to prevent skin complications? Select all that apply. Cleanse folds in the patient's skin. Assess the wound for excessive exudates. Irrigate wound drainage off the skin immediately. Use soap and hot water to clean and irrigate pressure ulcers. Apply a moisture-barrier ointment to skin around the wound.

Assess the wound for excessive exudates. Irrigate wound drainage off the skin immediately.

Which tasks can be delegated to a family member in regard to skin integrity and wound care? Assisting with hair care Assessing and evaluating a patient's skin and wounds Supervising UAP Deciding which medications the patient will take

Assisting with hair care

What are the types of wound edges?

Attached or unattached edges, rolled under (edible), macerated, fibrotic, callused

Which method of wound debridement is the slowest? Sharp Biologic Autolytic Mechanical

Autolytic

Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement?

Autolytic

The student nurse understands that a patient with enterocutaneous fistula has what type of opening? Between the muscle and the bone Between the skin and the intestines Between the lungs and the diaphragm Between the intestines and the vagina

Between the skin and the intestines An opening between the skin and the intestines is being described by the term "enterocutaneous." Entero means intestines and cutaneous means skin.

Which statement regarding heat and cold therapy is true? Heat therapy causes vasoconstriction. Edema is contraindicated with heat therapy. Cold therapy helps with wound debridement. Bleeding is contraindicated with heat therapy.

Bleeding is contraindicated with heat therapy.

Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity?

Bone. Tendon. Muscle.

Which evaluative cue would alert the nurse that a patient with a pressure injury is declining?

Braden Scale score was a 9 but is now an 8.

What type of wound drainage is considered sanguineous? Clear, watery plasma Bright red, active bleeding Thick and yellow, green, tan, or brown Pale pink, watery mixture of clear and red fluid

Bright red, active bleeding

Which dressing will the nurse use for a patient with a clean stage III pressure ulcer? None Adherent film Composite film Calcium alginate

Calcium alginate The nurse would use a calcium alginate dressing for a patient with a clean stage III pressure ulcer. No dressing is only appropriate for an intact stage I pressure ulcer. An adherent film dressing is appropriate for an unstageable pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer.

Which foods would the nurse recommend for a patient with a leg wound who needs to increase vitamin A intake?

Carrots Sweet Potatoes

How are wounds classified? Select all that apply. Size Color Cause Depth Presence or absence of infection

Cause Depth Presence or absence of infection

patient with diabetes is being seen in the emergency department for blood sugar issues. What is the most appropriate nursing action in this scenario? Checking the patient's feet Assessing the patient's reflexes Testing the patient's blood pressure Asking the patient about financial and insurance information

Checking the patient's feet

A nurse is working in the emergency department and a child was brought in with a burn on his arm. Which action made by the nurse demonstrates appropriate wound classification? Classifying the wound according to color. Classifying the wound according to the source of burn. Classifying the wound according to the degree of burn. Classifying the wound according to contamination factor.

Classifying the wound according to the degree of burn.

The nurse is preparing to clean and irrigate traumatic wounds on her patient's right leg and right arm. What should the nurse do? Clean with acetic acid and irrigate very gently. Clean with Dakin's solution and irrigate forcefully. Clean with hydrogen peroxide and irrigate with cold normal saline 0.9%. Clean with normal saline 0.9% and irrigate with room temperature normal saline 0.9%.

Clean with normal saline 0.9% and irrigate with room temperature normal saline 0.9%.

A nurse is preparing to perform vacuum-assisted wound closure. Which items does the nurse need? Select all that apply. Gauze Clear drape Suction tubing Foam dressing Negative-pressure setting device

Clear drape Suction tubing Foam dressing Negative-pressure setting device

Which action is involved in safely removing retention sutures? Cut the suture at the end nearest to the knot. Cut the suture as farthest to the skin edge as possible. Pull the visible part of the suture above the skin through underlying tissue. Clip suture materials nearest to the skin edge on one side, and pull from the other side.

Clip suture materials nearest to the skin edge on one side, and pull from the other side.

Which pressure injury stage is depicted in the image?

Correct 2 The nurse would classify this as a stage 2 pressure injury. It is a partial-thickness wound involving the epidermis and dermis. 1 A stage 1 pressure injury is intact skin with no blisters; this image does not have intact skin. 3 A stage 3 pressure injury would extend into the subcutaneous tissue; this image does not involve the subcutaneous tissue. 4 A stage 4 pressure injury would expose muscle, bone, tendons, and/or cartilage, and this is not shown in the image.

Which type of opening occurs in a patient who has an enterocutaneous fistula?

Correct Between the skin and the intestine An opening between the skin and the intestines is described as enterocutaneous. "Entero" means intestines, and "cutaneous" means skin. Between the muscle and the bone An opening between the muscle and the bone is not described as enterocutaneous. "Entero" means intestines, and "cutaneous" means skin. Between the bowel and the vagina An opening between the intestines (bowel) and the vagina is an enterovaginal fistula, not an enterocutaneous fistula. Incorrect Between the bladder and the colon An opening between the bladder and colon is not an enterocutaneous fistula. "Entero" means intestines, and "cutaneous" means skin.

Which complication would the nurse identify for the health care provider in a patient whose surgical incision "popped" open and is draining fluid?

Correct Dehiscence Dehiscence is a partial or complete separation of tissue layers and includes a "popping" sound with an increase in drainage. This accurately describes the scenario. Fistula A fistula is a connection between two parts of the body that are not normally connected. Incorrect Evisceration Evisceration is the total separation of tissue layers, allowing protrusion of visceral organs (intestines) through the incision. There is no mention of visceral organs being exposed in this scenario. Pressure injury Pressure injuries are wounds due to tissue ischemia, and they do not occur at incision sites. This scenario is not describing pressure injuries.

Which characteristic accurately describes the dermis?

Correct Is an area for sebaceous glands Sebaceous (oil) glands are located in the dermis. no- Consists of dead skin cells The epidermis, not dermis, consists of dead skin cells. no- Has the same thickness regardless of location Although the dermis is thicker than the epidermis, the thickness of the dermis varies depending upon the location. no - Contains adipose tissue The subcutaneous layer, not the dermis, contains adipose tissue.

Which statement regarding the skin is accurate?

Correct It is closely linked to personal identity. Skin is closely linked to personal identity and self-image. no- It has a minimal role in body temperature. Skin has a major (not minimal) role in body temperature regulation through perspiration and through constriction and dilation of blood vessels. no- It has no role in cultural perception. Skin is interwoven with cultural identity and perception, and it plays a role in cultural perception. no- It alerts a person to danger through electrolyte balance. Skin alerts a person to danger through tactile stimulation rather than through electrolyte balance.

Which characteristics of aging cause the skin to be fragile, loose, dry, and transparent?

Correct Loss of elastin Gradual loss of elastin causes skin to age and become loose. Correct A decrease in the number of sweat glands A decrease in the number of sweat glands causes dry skin. Correct A smoothing of the layer of skin under the epidermis A smoothing of the layer of skin under the epidermis causes skin to become more fragile. no- Thickening of the epidermis Thinning rather than thickening of the epidermis causes skin to become transparent. no -An increase in subcutaneous fat A decrease rather than increase in subcutaneous fat causes skin to hang loosely.

Which phase of wound healing is characterized by a patient who reports that the bumpy and granular injured site "bleeds easily"?

Correct Proliferative The proliferative phase is the phase of healing and repair in which new tissue bleeds easily and has a granular and bumpy texture. Maturation The maturation phase is the final phase of wound healing and is also known as remodeling. In this phase, collagen continues to be deposited, and a scar is formed and strengthened. Unstageable Unstageable is a classification given to stages of pressure injuries. It is not a phase of wound healing. Inflammatory The inflammatory phase is the first phase of wound healing, and it involves bleeding, which is the body's first response to a wound; however, the injured site does not have a bumpy, granular appearance in this phase.

Which classification would the nurse use for staging a pressure injury that has a full-thickness wound and extends into the subcutaneous tissue, but not into the fascia, muscle, or bone?

Correct Stage 3 Stage 3 pressure injuries are characterized by full-thickness wounds that extend into the subcutaneous tissue, but not into the fascia, muscle, or bone. no- Stage 1 Stage 1 pressure injuries are characterized by intact, nonblistered skin. no- Stage 2 Stage 2 pressure injuries are characterized by partial-thickness wounds involving the epidermis and dermis. no- Stage 4 Stage 4 pressure injuries are characterized by full-thickness wounds that are deeper than stage 3 pressure injuries and expose muscle, bone, or connective tissue.

What two primary complications of wound healing can occur when tissues of surgical incisions are under physical stress? Infection and bruising Dehiscence and infection Evisceration and infection Dehiscence and evisceration

Dehiscence and evisceration

What is the advantage of a moist application in wound healing? Does not promote sweating Does not cause skin maceration Retains temperature longer Less risk for burns to the skin than dry applications

Does not promote sweating A warm, moist application does not promote sweating, so it limits unnecessary fluid loss. A dry, not moist, application does not cause skin maceration. Dry, not moist, heat retains temperature longer, because evaporation does not occur. Dry heat carries less risk for burns skin than does moist heat.

What characteristics related to skin may reflect an overall health problem? Select all that apply. Dryness Turgor Wounds Odor Skin tone

Dryness Turgor Wounds Odor

Which factors are related to pressure ulcers? Select all that apply. Duration Obesity Intensity Moisture Immobility

Duration Intensity Moisture Immobility

The nurse is planning can for a patient on bedrest and has a goal of "Patient will maintain an oxygen saturation of 92% or higher during hospitalization." What interventions will help achieve this goal?

Encouraging the patient to cough and deep breathes Turning the patient every 2 hours Elevating the head of the bed to at least 30 degrees Teaching the appropriate use of an incentive spirometer every house while awake

A patient enters the emergency department with a third-degree burn on his stomach. The patient stated that the burn is painless. Which layer of skin was most likely affected? Epidermis Upper dermis Entire dermis Hypodermis

Entire dermis

A patient enters the emergency department with a third-degree burn on his stomach. The patient stated that the burn is painless. Which layer of skin was most likely affected?

Entire dermis.

A wound care nurse practitioner is examining a patient's decubitus ulcer on the lateral malleolus and suspects that it is an infected decubitus. Which findings would the nurse likely find during the wound assessment? Select all that apply. Erythema noted on the superior portion of the ulcer Purulent, malodorous drainage 1.5 cm wound with serous drainage and tissue epithelialization Temperature of 102° F Patient reports a pain level of 3/10 during the exam

Erythema noted on the superior portion of the ulcer Purulent, malodorous drainage Temperature of 102° F Patient reports a pain level of 3/10 during the exam

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat?

Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

A boy is admitted with diffuse abrasions or "road rash" from trauma. Large areas of his epidermis are missing. Which will be affected by these abrasions? Body temperature Fluid and electrolytes Protection over bony prominences Blood supply

Fluid and electrolytes

A boy is admitted with diffuse abrasions or "road rash" from trauma. Large areas of his epidermis are missing. Which will be affected by these abrasions?

Fluid and electrolytes.

A patient's wound is producing a moderate amount of drainage. When the patient is in respiratory distress, the wound drainage is excessive. What dressing should the nurse choose for this patient's wound? Gel Foam Transparent Hydrocolloid

Foam

Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of wound drainage?

Foam

Describe the contribution of the musculoskeletal

Form and support Joints - stability and mobility Protection Blood cells & immunity Storage (Ca, Mg, PO4, Protein)

What external forces can result in pressure ulcers? Select all that apply. Friction Massage Pressure Movement Shear force

Friction Pressure Shear force

unstageable pressure ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

Pressure ulcer stage 4

Full-thickness wound that is deeper than a stage III wound Involves exposure of muscle, bone, or connective tissue (tendons, cartilage) Infection of the bone, if exposed, is highly likely

Pressure ulcer unstageable

Full-thickness wound with necrotic tissue (eschar) Assessment of wound depth or involvement of underlying tissues is not possible

Pressure ulcer stage 3

Full-thickness wounds extending into the subcutaneous tissue, but not into fascia, muscle or bone May include undermining (tissue loss around edges and under intact skin, forming a lip around the wound) May include tunneling (narrow passage-way extending out from the wound)

A nurse admits a trauma patient and prepares to care for his multiple wounds. Which wound closure materials could the nurse anticipate using? Select all that apply. Glue Staples Steri-Strips Nylon sutures Catgut sutures

Glue Staples Nylon sutures Catgut sutures

A patient has a 1 cm × 1 cm × 0.5 cm pressure ulcer on his occiput that involves the epidermis and dermis (Stage 2). The nurse provides anticipatory guidance to the parent, explaining that which may occur?

Hair loss.

Which statement regarding dressings is true? Gauze is an effective barrier against microorganisms. Hydrocolloids are inappropriate for infected wounds. Hydrocolloids have fibers that may slough off into wounds. Transparent dressings are best for wounds with moderate drainage.

Hydrocolloids are inappropriate for infected wounds.

Which type of dressing is preferred for dry wounds? Hydrogel Hydrocolloid Calcium alginate Debriding enzymes

Hydrogel

Describe the importance of hygiene in the clinical setting

Hygiene is a way to help prevent the spread of infections.

The student nurse is learning how to classify burn wounds. Which statement made by the student nurse reflects a misunderstanding? "I can classify burn wounds according to the depth of the lesion." I can classify burn wounds according to the depth and width of the lesion." "The wound cannot be classified according to what caused the burn lesion." "The wound cannot be classified according to the resulting damage to the epidermis."

I can classify burn wounds according to the depth and width of the lesion." Burn wounds are not classified according to how wide the lesion is, so this statement shows a misunderstanding on the part of the student nurse.

A patient has a pressure ulcer through all layers of the epidermis with the dermis exposed. Due to the ulcerated epidermis, what will be compromised? Blood supply to the skin Temperature regulation Protection over bony prominences Immune response

Immune response

A patient has a pressure ulcer through all layers of the epidermis with the dermis exposed. Due to the ulcerated epidermis, what will be compromised?

Immune response.

For which patient hypotheses would the nurse select turning and positioning as a solution?

Impaired Skin Integrity. Risk for Pressure Ulcer/Injury. Impaired Tissue Integrity. Risk for Impaired Skin Integrity.

What are the three stages of healing?

Inflammatory Proliferactive Maturation

3 phases of wound healing

Inflammatory phase, which includes homeostasis Proliferative phase Maturation phase (remodeling)

Pressure ulcer stage 1

Intact, non-blistered skin Non-blanchable erythema or persistent redness in the area of pressure (abnormal reactive hyperemia) Painful area that differs in firmness and temperature from surrounding tissues

Which statement is true about the skin?

It is closely linked to person identity.

Which statement is true about the skin? It has no role in body temperature. It is closely linked to personal identity. It has nothing to do with cultural identity. It alerts to danger through electrolyte balance.

It is closely linked to personal identity.

What are the steps involved in wound undermining? Select all that apply. Laterally insert the cotton tipped applicator into the widest section. Mark the area on the stick end of the applicator that is even with the edges of the skin. Administer pain medication. Measure the distance from the top of the applicator to the marked are to determine depth. Measure any changes in the surrounding skin that may indicate infection.

Laterally insert the cotton tipped applicator into the widest section. Mark the area on the stick end of the applicator that is even with the edges of the skin. Administer pain medication. Measure the distance from the top of the applicator to the marked are to determine depth.

How to measure a wound?

Length - head to toe direction Width - hip to hip direction Depth - measure deepest part of visible wound bed

An adult patient recently had a partial gastrectomy. At present, the patient is NPO and receives total parenteral nutrition (TPN). Using the Braden Scale, what would be the expected level of the patient's nutritional status? Level four or excellent Level two or probably inadequate Level one or very poor Level three or adequate

Level three or adequate

In a focused wound assessment, what data should be collected? Select all that apply. Location and size Presence of tunneling Pain tolerance Drainage Wound bed, edges, and surrounding tissues

Location and size Presence of tunneling Drainage Wound bed, edges, and surrounding tissues

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity?

Low pre-albumin levels. Immobility. Stage 2 pressure injury.

A nurse is caring for an underweight older adult female. What should the nurse consider about weight and functions of the skin?

Low weight means less subcutaneous tissue.

Which are potential skin complications for a patient with a continually-draining surgical wound? Select all that apply. Rash Maceration Dehiscence Skin infection Pressure ulcers

Maceration Dehiscence Skin infection Pressure ulcers

A nurse is caring for a patient with deep partial-thickness burns. The patient was admitted to the hospital 18 hours ago and sustained the injury 20 hours ago. Which nursing actions are most important during this stage of wound care? Select all that apply. Maintaining airway Controlling chronic pain Applying prescribed topical medications Preventing fluid and electrolyte imbalance Implementing measures to preserve function

Maintaining airway Applying prescribed topical medications Preventing fluid and electrolyte imbalance

A nurse is caring for an older adult male with a sacral decubitus. The nurse is required to measure the dimensions of the wound. Which steps would the nurse take? Select all that apply. Measure the depth by inserting the end of a sterile cotton-tipped applicator down into the deepest portion of the wound. Measure the width laterally from left to right at the widest portion of the wound. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. Measure the length vertically from the top to the bottom at the widest open area of the wound. Measure the width laterally by measuring the smallest portion of the wound from left to right.

Measure the depth by inserting the end of a sterile cotton-tipped applicator down into the deepest portion of the wound. Measure the width laterally from left to right at the widest portion of the wound. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. Measure the length vertically from the top to the bottom at the widest open area of the wound.

Which factors affect skin integrity? Select all that apply. Medications Vascular diseases Excessive dryness Nutritional deficits Darkness exposure

Medications Vascular diseases Nutritional deficits

An adolescent expresses concern to the nurse about how she will look in a bathing suit after her leg wound heals. Which primary goal of wound closure is the patient most concerned about? Prevention of pain Prevention of infection Minimization of scarring Minimization of ecchymosis

Minimization of scarring

Which action is inappropriate for maintaining an airtight seal in negative-pressure wound therapy? Avoiding adhesive removers Moistening the periwound area thoroughly Framing the periwound area with skin sealant Filling uneven skin surfaces with a skin-barrier product

Moistening the periwound area thoroughly To maintain an airtight seal, the periwound area should be dried thoroughly, not moistened. The remaining actions are appropriate. Adhesive removers should be avoided because they leave a residue that hinders film adherence. The periwound area should be framed with skin sealant. Uneven skin surfaces should be filled with skin-barrier products.

Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)?

Monitor for granulation tissue in the wound. Avoid using NPWT for a patient with a cancerous wound. If the patient reports pain, change from the black foam to white foam. Report to the health care provider if there is an increase in wound drainage.

The nurse is caring for a patient who is taking acetaminophen-hydrocodone for pain following a total knee replacement. Prior to ambulating the patient the nurse will complete each of the following actions. What is priority?

Monitoring the patients vital signs and stability with position changes

Which statement regarding burn care is true? Antibiotic ointment should be avoided. The burn should be cleaned with alcohol. The burn should be cooled to concentrate heat. NSAIDs or a narcotic should be administered for pain.

NSAIDs or a narcotic should be administered for pain.

What is embedded in the dermis? Select all that apply. Nerves Fat tissue Lymphatics Sweat glands Hair and nail follicles

Nerves Lymphatics Sweat glands Hair and nail follicles

A nurse is preparing to clean a wound bed and wants to avoid cell damage. Which solution should the nurse select? Dakin's solution Povidone-iodine Hydrogen peroxide Normal saline 0.9%

Normal saline 0.9%

A nurse is preparing to irrigate a wound. What should the nurse consider? Irrigation fluid should be cold. Normal saline 0.9% is an effective irrigate solution. Forceful irrigation is necessary to thoroughly clean wounds. Irrigating a wound can decrease leukocyte activity, promoting healing.

Normal saline 0.9% is an effective irrigate solution.

Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage?

Notify the primary health care provider. Take the patient's temperature. Review white blood cell count.

Which actions would the nurse take for a patient receiving heat therapy?

Obtain distilled water for aquathermia treatments. Check on the disoriented patient more frequently. Cover the container and hand when providing warm hand soaks.

The nurse is classifying a wound in her chart. The nurse understands that which documentation would be a standard classification that other health care workers would be able to comprehend? Slice wound that is very dirty Open wound with raised scar tissue Round wound with purulent drainage Open knife wound with contamination

Open knife wound with contamination An open knife wound with contamination is documentation that others would comprehend, as wounds are classified by cause (in this case a knife), as well as whether they are contaminated.

A patient has a decubitus ulcer that is 1 cm deep and 2 cm wide by 3 cm long. The nurse notices the superior margin of the wound has significant undermining. How can the nurse describe "undermining" to the patient's family so they have a better understanding of the wound? A deeper area of an ulcer caused by a high volume of pressure forced upon tissue layers, creating a sink-hole-like effect in the wound. Overhanging skin edges at the margin of the wound; in essence, the pressure ulcer is larger at its base compared to the skin surface. A form of cell injury which results in the premature death of cells in living tissue by autolysis. The act of shedding or casting off dead tissue.

Overhanging skin edges at the margin of the wound; in essence, the pressure ulcer is larger at its base compared to the skin surface.

Describe the contributions of the cardiopulmonary system

Oxygenation and perfusion Nutrients Waste removal Literally everything

Describe the contribution of the nervous system

PNS vs CNS (Afferent and efferent pathways) PNS: Autonomic and Somatic Left side vs right side Neurotransmitters

Which parameters would the nurse monitor after applying a wrap to an ankle? Correct

Pain. Pallor. Paralysis. Paresthesia. Pulselessness.

A patient is recovering from surgery. After the sixth day of recovery, which action made by the nurse indicates proper assessment of how the patient's incision is healing? Asking the patient if any pain is felt Charting the incision line's color and tenderness Removing all sutures and stables around the wound Palpating the area of induration next to the incision line

Palpating the area of induration next to the incision line

Dehiscence

Partial or complete separation of tissue layers

Pressure ulcer stage 2

Partial-thickness wound involving the epidermis and dermis Shallow and superficial with a pink wound bed Also includes intact or ruptured blisters from pressure that have not yet cratered

The nurse is caring for an older adult patient in a sub acute rehab setting who recently suffered a cerebral vascular accident (CVA) and has a right hemiparesis. The patient requires maximum assistance for repositioning in the bed wheelchair. According to the Braden Scale, the patient's risk for shearing and friction falls into which category? No apparent problem, or level three Potential problem, or level two Problem, or level one Potential problem, or level three

Potential problem, or level three

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound?

Patient will eat a high-protein diet at every meal. Patient will help with transfers within 24 hours.

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident?

Patient's wound will exhibit granulation tissue in the wound by 1 week.

How does sensory loss relate to the formation of a pressure ulcer? Patients may be at risk of too much friction. Patients may be unable to feel pain or discomfort. Patients may be unable to detect the onset of malnutrition. Patients may be unable to notice the warning signs of maceration.

Patients may be unable to feel pain or discomfort.

A nurse is caring for an adolescent patient with asthma who is able to ambulate. Which aspect of skin hygiene should the nurse focus on for this patient? Preventing perspiration Limiting skin exposure to stool Limiting skin exposure to urine Preventing use of a moisturizer

Preventing perspiration

Match the type of healing to its characteristic.

Primary Intention- Healing that is swift and uncomplicated in an acute wound with minimal scar tissue Examples: Surgical incisions or traumatic wounds in which the edges of the wound can be brought together (approximated); may or may not need sutures secondary Healing that starts from the bottom and sides of the wound until new tissue fills the wound bed; larger amounts of tissue loss that take longer to heal Examples: Chronic wounds or wounds associated with chronic diseases, such as diabetes or vascular disease, or with other factors that hinder normal wound healing Tertiary Intention Healing in which the wound is initially left open, causing a delay between injury and closure Examples: Contaminated surgical wounds left open to allow infectious material to exit the wound (common in gastrointestinal tract); closed (sutured) later when infection risk is reduced Healing is from the bottom and sides of the wound. secondary intention Edges are approximated. Primary Intention- There is a delay between injury and closure. Tertiary Intention

The nurse is caring for a patient with a recent, minor injury. As the nurse assesses the site of the injury, she notes that the new tissue has a granular, bumpy texture. The patient reports that the injured site still "bleeds easily." The nurse understands the phase of wound healing by documenting which stage in the patient's chart? Maturation Unstageable Proliferative Inflammatory

Proliferative The proliferative phase is the phase of healing and repair, in which new tissue bleeds easily and has a granular and bumpy texture. This is correctly observed in the patient in this scenario.

The nurse tells the patient he will be turned every two hours to keep his skin from "breaking down" and causing infection. The nurse knows that intact skin supports which function of the skin? Production of Vitamin D Release of toxins Regulation of heat Protection

Protection

The nurse tells the patient he will be turned every two hours to keep his skin from "breaking down" and causing infection. The nurse knows that intact skin supports which function of the skin?

Protection.

Which action by the nurse is priority when providing discharge teaching to a patient and spouse about wound care when the spouse is the primary caregiver?

Provide written instructions.

Which are functions of the basale layer of the epidermis? Select all that apply. Helps produce friction and shear. Provides skin coloring and protects it from ultraviolet light. Produces new cells that push through to the stratum corneum. Gives the skin strength and flexibility and allows it to repair itself. Helps provide environmental protection and regulates fluids and electrolytes.

Provides skin coloring and protects it from ultraviolet light. Produces new cells that push through to the stratum corneum. Gives the skin strength and flexibility and allows it to repair itself.

Match the type of wound to its typical colors.

Purple or maroon Suspected deep-tissue injury White, brown, or black Full-thickness burn Beefy red and bumpy Wound in proliferative phase Red and purulent Infected wound

Suspected deep tissue injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Braden scale

Ranks patients on risk categories of sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Score lower than 18 places the patient at risk for pressure ulcer development. If the patient scores particularly low in one or more categories, preventive strategies can be directed more precisely at those specific areas to decrease overall risk.

Norton scale

Ranks risk based on the patient's physical condition, mental state, activity, mobility, and continence. Lower score indicates higher risk. Understanding definitions of different categories is essential for arriving at a risk score that is reflective of actual risk.

Which action would the nurse take when caring for a patient's Jackson-Pratt drain?

Reactivate the drain after emptying.

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound?

Repositioning the patient. Reporting any changes in patient's skin integrity or condition. Applying a non-sterile dressing for chronic wounds with an established treatment plan.

Which of a novice nurse's actions would necessitate intervention when providing care for a patient who is prescribed negative-pressure wound therapy? Retaining hair around the wound Using a skin barrier around the wound Drying around the wound thoroughly Filling uneven wound surfaces with a hydrocolloid product

Retaining hair around the wound Retaining hair around the wound edges can cause an air leak, so this action requires correction. Using a skin barrier, drying around the wound thoroughly, and filling uneven wound surfaces with a hydrocolloid product are all appropriate and will help maintain an airtight seal.

A patient has a post-operative follow-up appointment with the nurse. During the appointment, the nurse removes the patient's dressing and observes that the wound appears infected. Which action by the nurse demonstrates proper knowledge of wound healing and skin integrity? Assessing the patient's appetite Reviewing the patient's medications Checking the patient for signs of exhaustion Asking the patient about stressors in the home

Reviewing the patient's medications

Which hypothesis would the nurse develop for an immobile patient who has intact skin?

Risk for impaired skin integrity.

Which are benefits of using a binder over or around a dressing? Securing a splint Reducing edema Allowing the body part freedom to move Creating pressure over the body part Preventing infection

Securing a splint Reducing edema Creating pressure over the body part

A nurse is performing debridement for a patient with hemophilia. Which type of debridement especially requires caution for this patient? Sharp Biologic Autolytic Enzymatic

Sharp

A middle-aged female is admitted for surgery. She states she is embarrassed about her weight. She is 5 feet 7 inches tall and weighs 190 pounds. What does the nurse realize about the patient?

Skin is connected with body image, and subcutaneous tissue is affected by age and gender.

What is characteristic of stage III pressure ulcers? Underlying muscle is exposed Slough may be present with slough, but it does not obscure the depth of tissue loss. Discoloration of the skin, warmth, edema, hardness, and/or pain may be present. It presents as a shallow, open ulcer with a red-pink wound bed without slough.

Slough may be present with slough, but it does not obscure the depth of tissue loss.

A nurse is caring for a patient with paralysis who has a full-thickness wound that extends into the subcutaneous tissue, but not into the fascia, muscle, or bone. The nurse demonstrates knowledge of wound classification by documenting the pressure ulcer as which stage? Stage I Stage II Stage III Stage IV

Stage III

Which pressure ulcer is expected to heal through granulation and reepithelialization? Stage I Stage II Stage IV Unstageable

Stage IV Stage IV pressure ulcers are expected to heal through granulation and reepithelialization. Wound care for a stage I pressure ulcer is aimed at slow healing without epidermal loss over 7 to 14 days. Stage II pressure ulcers are expected to heal through reepithelialization. Wound care for an unstageable pressure ulcer includes debridement done to soften the eschar.

A patient presents to the emergency department with a superficial, non-contaminated wound that occurred within the last hour. Which type of wound closure is most appropriate for this patient? Gauze Staples Sutures Steri-Strips

Steri-Strips

What are primary sources of contamination for skin? Select all that apply. Stool Urine Blood Perspiration Wound drainage

Stool Urine Perspiration Wound drainage

The nurse is careful to elevate her patient's head of bed 30 degrees and uses a draw sheet to move her patient. In doing these things, she is protecting which layers of the epidermis? Stratum corneum and stratum lucidum Stratum lucidum and stratum germinavatum Stratum germinavatum and stratum spinosum Stratum lucidum and stratum spinosum

Stratum lucidum and stratum spinosum

The nurse is careful to elevate her patient's head of bed 30 degrees and uses a draw sheet to move her patient. In doing these things, she is protecting which layers of the epidermis?

Stratum lucidum and stratum spinosum.

Which adjuvant treatments are only considered for patients diagnosed with clean stage IV or unstageable pressure ulcers? Support hydration Nutritional support Surgical consultation for closure Surgical consultation for debridement Evaluation of pressure-redistribution needs

Surgical consultation for closure Surgical consultation for debridement

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days?

Therapies consistent with guidelines for treatment of wounds. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN). Agreement of the patient with the treatment plan. Capability of the patient to purchase supplies for home care as required.

Which statements are true about superficial- or partial-thickness wounds? Select all that apply. These wounds tend to heal quickly. These wounds affect only the dermis. Superficial wounds affect only the epidermis. These wounds usually take a very long time to heal. Partial-thickness wounds affect the epidermis and the dermis, but do not extend through the dermis to the subcutaneous layer.

These wounds tend to heal quickly. Superficial wounds affect only the epidermis. Partial-thickness wounds affect the epidermis and the dermis, but do not extend through the dermis to the subcutaneous layer.

Superior

Top, up

Evisceration:

Total separation of tissue layers, allowing protrusion of visceral organs through incision

Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with minimal drainage?

Transparent

Which instruction for turning and positioning is correct? Turn patient every 2 hours; elevate head of bed 30 degrees Turn patient every 4 hours; elevate head of bed 30 degrees Turn patient every 2 hours; elevate head of bed 45 degrees Turn patient every 4 hours; elevate head of bed 45 degrees

Turn patient every 2 hours; elevate head of bed 30 degrees

Which actions would the nurse take for a comatose patient who has frequent liquid stools and has a Braden Scale score of 8?

Turn the patient every 2 hours for Pad and protect any bony prominences. Wash and dry the patient's skin after each liquid stool. Replace soiled

Which techniques would the nurse use to troubleshoot issues with patients' dressings?

Use an abdominal binder to help a patient who has an abdominal wound to cough. Use Montgomery straps for a patient who needs frequent dressing changes. Use a splint to help a patient who has an abdominal incision to deep breathe.

Which action would the nurse take when irrigating a patient's abdominal wound?

Use sterile technique.

Which nursing action is appropriate when providing care to a patient who exhibits no risk for skin breakdown? Using a standard surface Using a pillow under the calves Using an active support surface Using a pressure-redistribution seat cushion

Using a standard surface

Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis? Zinc Protein Vitamin C Vitamin A

Vitamin A

The absence of adequate amounts of which nutrient in the diet may impair inflammatory response in wound healing? Zinc Proteins Vitamin A Vitamin C

Vitamin A Vitamin A plays a major role in the inflammatory response in wound healing, so a lack of it can impair the inflammatory response. Zinc plays a role in collagen formation and protein synthesis during wound healing. Proteins promote fibroplasia, angiogenesis, collagen formation, and immune function during wound healing. Vitamin C promotes collagen synthesis and capillary wall integrity, and provides antioxidant benefits to support wound healing.

An older adult patient is being treated for edema in the feet. Which therapy is most appropriate for the patient? Warm Sitz bath Warm moist soak Warm moist compress Warm aquathermia pads

Warm moist soak

What can impart the function of the MSK system?

Weakness Atrophy Contracture Weakened bone structure Joint stiffness

Which tools may be used to track wound healing? Select all that apply. Braden Scale Wound Characteristic Instrument Norton Scale Pressure Sore Status Tool (PSST) Pressure Ulcer Scale for Healing (PUSH) tool

Wound Characteristic Instrument Pressure Sore Status Tool (PSST) Pressure Ulcer Scale for Healing (PUSH) tool

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum?

Wound, ostomy, and continence nurse (WOCN). Social worker. Nutritionist.

Blanket suture

a continuous self-locking stitch.

Continuous sutures

a series of stitches, but they are not individually knotted.

Fistula

abnormal connection between two organs or an organ and outside the body

Epithelialization

appear deep pink, progress to pearly pink/light purple from the edges in full thickness wound

Retention sutures

are placed more deeply than skin sutures

If a patient who is day 1 post knee replacement, what would you assess prior to a therapist coming to work on movement?

assess her pain and give any kind of pain medications doctor would like for her to have prior to therapy

Scar tissue

avascular collection of collagen

Distal

away from center

Dermis layer of skin

hair follicle layer

Posterior

back, underside

Granulation tissue

beefy red, granular, bubbly in appearance; red, pink, pale pink, full dusky red

Inferior

below, down

Subcutaneous layer of skin

blood vessel layer

Which nutrients would need to be increased in the diet of a patient with full-thickness burns?

correct - Zinc Zinc is essential for healing the skin that is burned. Correct Copper Copper is needed for healing of the skin. Correct Protein Fibroblasts need protein to make collagen. Correct Vitamin A Vitamin A would be needed for healing of the burn. Correct Vitamin C Vitamin C would be needed for collagen formation. Incorrect Vitamin D Although vitamin D is important, it would not be needed in additional quantities for healing a full-thickness burn.

Which strategy would the nurse use to classify a burn?

correct - According to the skin layer damaged Classifying the burn according to the skin layer damaged is a common strategy, and the categories include superficial, partial thickness, and full thickness. According to drainage Although drainage is important, it is not a strategy to classify a burn. According to source of burn Classifying the burn according to its source is not appropriate, as this is not one of the classifications for burns. Correct According to contamination factor Classifying the burn according to contamination factor is not appropriate. Although wounds can generally be classified according to contamination, this is not appropriate for burns.

Which cells join the epidermis and dermis and are arranged in a single layer?

correct - Basal cells Basal cells compose a single layer of active cells that join the epidermis and dermis. Incorrect Melanocytes Melanocytes produce melanin, which gives skin its color; they are not arranged in a single layer that joins the epidermis and dermis. Fibroblasts Fibroblasts produce collagen, which helps in wound healing; they do not compose a single layer of cells. Keratinocytes Keratinocytes produce keratin, a protein that provides strength and flexibility as well as the reparative ability of the skin to heal itself; they do not compose a single layer that joins the epidermis and dermis.

Which factors can directly cause the fibroblasts and collagen to be altered or ineffective in the proliferative phase of wound healing?

correct - Prolonged decrease of oxygen perfusion to skin A prolonged decrease of oxygen perfusion to the skin reduces the production of cells that produce collagen (fibroblasts) and decreases collagen formation. Correct Lack of protein A lack of protein would directly affect collagen because protein is needed for fibroblasts to make collagen. Correct Lack of vitamin C A lack of vitamin C would directly affect collagen because vitamin C is needed for collagen formation. Incorrect Too much moisture Too much moisture would lead to infection but would not directly affect fibroblasts and collagen. incorrect Minimal shear Minimal shear would have no effect on fibroblasts and collagen. Shear is the effect of gravity combined with friction Correct History of diabetes Diabetes leads to a decrease in collagen synthesis and strength. Thus, diabetes directly affects collagen.

Which effect on the wound would likely occur if a patient with pressure injuries smoked?

correct - Receives less oxygen The wound would receive less oxygen because of vasoconstriction and hemoglobin's decreased ability to transport oxygen. no- Has increased bleeding Bleeding would decrease (not increase) because nicotine causes vasoconstriction and increases the clotting ability of blood. Incorrect Contains weak macrophages Weak macrophages result from diabetes, not from smoking. no- Will be surrounded by dilated vessels Nicotine causes vessels to constrict, not dilate.

Which patient situation is a medical emergency?

correct - Shock A patient experiencing shock is a medical emergency because it indicates the patient is hemorrhaging internally or externally. Incorrect Stage 4 pressure injury Although a stage 4 pressure injury is critical, it is not a medical emergency because it is not life-threatening. Wound infection A wound infection is not life-threatening and is therefore not a medical emergency. Superficial burn A patient with a superficial burn has injured the epidermis, the outermost layer of skin. This is not a medical emergency.

Which response is likely when a patient who has a full-thickness wound receives a steroid?

correct Healing time will slow. Steroids, which are antiinflammatories, interrupt the inflammatory process, making patients prone to infections and slow healing. Incorrect Infection will be eliminated. Antibiotics, not steroids, eliminate infection. Malnutrition will result. Malnutrition is caused by a lack of nutrients, not by steroids. Shear will be decreased. Shear is a combination of gravity and friction; it is not related to steroids.

Which interpretation would the nurse make about a wound that is colonized?

correct- Contains microorganisms on the surface of the wound only A colonized wound contains one or more microorganisms on the surface of the wound, with no clinical signs of a wound infection. Has been contaminated with bacteria from a perforated appendix A contaminated (not colonized) wound is at high risk for infection due to bacteria-loaded fluid from a perforated appendix. Has a bacterial count of more than 105 per gram of tissue An infected (not colonized) wound has a bacterial count of more than 105per gram of tissue. Incorrect Contains pathogens in and on the wound with clinical signs of infection An infected (not colonized) wound has pathogens in and on the wound with clinical signs of infection. A colonized wound has no clinical signs of infection.

Tunneling

course of pathway that can extend in any direction from the wound. results in dead space

Eschar

darker in color, thicker and hard consistency black or brown in color

Firmly adherent

does not pull away from wound

Snus tact

drainage pathway from a deep focus of acute infection through tissue and/or bone to an opening on the surface

Intermittent sutures

each individual suture is made in the skin.

Nonadherent

easily separated from wound base

Epidermis layer of skin

epithelial layer

Anterior

front, top

Stage 3 pressure ulcer

full thickness tissue loss with visible fat

Which features describe the subcutaneous layer of skin?

no- is the outermost layer of skin The subcutaneous layer is the innermost, not the outermost, layer of skin. The epidermis is the outermost layer of skin. Incorrect Delivers blood to the epidermis The subcutaneous layer delivers blood to the dermis, not the epidermis. The dermis delivers blood to the epidermis. Correct Provides insulation to protect against both heat and cold The subcutaneous layer does provide insulation to protect against both heat and cold. Correct Cushions bony prominences and internal organs The subcutaneous layer does provide cushioning for bony prominences and protection of internal organs. no- Is involved in the digestion of bacteria The Langerhans cells in the epidermis, not the subcutaneous tissue, are involved in the digestion of bacteria.

Adipose tissue layer of skin

not good blood flow, fatty layer

Colonized wound

one or more organisms identified on the surface of the wound by culture without overt signs of infection

Dehiscence

partial or complete separation of tissue layers during healing

Stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both

Sanguineous

thin, bright red

Serous

thin, watery, clear

Serosanguineous

thin, watery, pale red to pink

Foul purulent

this opaque yellow o green with offensive odor

Undermining

tissue destruction underlying intact skin along wound margins

Evisceration

total separation of tissue layers with protrusion of viscera

Proximal

toward center, nearest

Medial

toward middle

Lateral

toward side

Purulent

which or thin, opaque tan to yellow

Approximation

wound edges that are brought neatly together

Superficial wound

wound involving only the epidermis

Partial-thickness wound

wound involving the epidermis and dermis

Acute wound

wound progresses rapidly through stages of the healing process

Scant

wound tissues moist, no measurable drainage

Closed Wound

wound without an open area on the skin