Chapter 31: Skin Integrity and Wound Care

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?

"Steri-Strips will hold my wound together until it heals."

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

A client sitting in a chair who slides down

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

Elevate and support the stump.

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?

Penrose drain

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

contusion

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar

Which type of wound drainage should alert the nurse to the possibility of infection?

foul-smelling drainage that is grayish in color

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?

hydrocolloid dressings

A skin infection caused by beta-hemolytic streptococci common in children is:

impetigo.

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?

incision

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention.

The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot, and injured the worker's foot. What type of injury does the nurse anticipate?

puncture

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

surgical incision with sutured approximated edges

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective

"I will put a layer of cloth between my skin and the ice pack."

The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What is the appropriate nursing response? Select all that apply.

"Medical maggots are sterilized before they are introduced to the wound." "I understand your concern; let's talk further about your thoughts about this treatment." "The choice regarding whether to have or decline this treatment is yours."

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include?

"Very little scar tissue will form."

The nurse is discussing home remedies for insect bites with a group of college students. The nurse correctly includes which remedy in the presentation?

Aloe vera

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention?

Apply sterile dressings with normal saline over the protruding organs and tissue.

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

Assess the wound for active bleeding.

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?

Braden scale

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication?

Evisceration

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy. Which interventions should the nurse follow to apply the T-binder? (Select all that apply.)

Fasten the crossbar around the waist. Pass the tails through the client's legs. Pin the tails to the belt of the T-binder.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

Fish

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing describes this?

Secondary intention

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

Stage II

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury

Stage IV

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure injury?

Support the client from sliding in bed.

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

Supports the area around the wound

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion?

Tearing of a structure from its normal position

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?

Tegaderm

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

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

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

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

removing dead or infected tissue to promote wound healing

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care?

Cleanse with a new gauze for each stroke.

Which is not considered a skin appendage?

Connective tissue

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

Gauze

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage?

Serosanguineous

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

Serosanguineous

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

Stage III

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:

second degree or partial thickness