Chapter 32:Skin Imtegrity and Wound Care

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

"Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." **"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." "Be sure to take at least two showers daily to remove all microorganisms from the skin."

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"You will receive medication through this device." "Drainage will occur by gravity and capillary action." "The bulb-like system will stay in place permanently after your mastectomy." "It provides a way to remove drainage and blood from the surgical wound."

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

**Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Use an aquathermia pad during the treatment to create heat and circulate the water. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles. SUBMIT ANSWER

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client?

**Monitor intake and output. Assess the coccyx area for blanching. Assess mental status. Monitor the client for nausea.

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad?

100°F to 104°F (37.7°C to 40°C) **105°F to 109°F (40.5°C to 43°C) 110°F to 115°F (43.3°C to 46.1°C) 90°F to 99°F (32.2°C to 37.2°C)

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

Allow the wound and intestinal contents to remain open to air. Pack the wound with gauze pads and a dry sterile dressing. Inform the client that this is an expected occurrence and not to worry. **Apply saline solution-moistened gauze over the protruding area.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Rotate the swab several times over the wound surface to obtain an adequate specimen. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse?

Consult a wound care nurse. Document the findings. Send the client to the emergency room. Notify the health care provider.

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

Decreased radial pulse Warm hand **No finger numbness or tingling **Fingers with quick capillary refill Cyanosis

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?

FLACC scale Morse scale Glasgow scale **Braden scale

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

If there is contamination of dirt and debris Staging the wound for assessment The event leading up to the trauma **The status of the client's tetanus immunization

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?

Pasta salad Green beans Banana **Fish

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

The margins of your wound are not in direct contact." "The surgeon will leave your wound open intentionally for a period of time." "This is a complex reparative process." **"Very little scar tissue will form."

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?

This is normal tissue." "That is called undermining, a type of tissue erosion." **"That is necrotic tissue, which must be removed to promote healing." "That is old clotted blood underneath the wound"

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

To turn the head away from the area whenever coughing To ambulate using a cane or walker To remain in bed for the next 4 hours **To splint the area when engaging in activity

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 who lies on wrinkled sheets **a client sitting in a chair who slides down a client who must remain on the back for long periods of time a client who lifts himself up on the elbows

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site?

a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics **a transparent film a gauze dressing precut halfway to fit around the IV li

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

alginate transparent film **hydrocolloid hydrogel

Which is not considered a skin appendage?

connective tissue

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

dehiscence hemorrhage fistula **evisceration

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

elevate the head of the bed 90 degrees place a foot board on the bed use pillows to maintain a side-lying position as needed **provide incontinent care every 4 hours as needed

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection?

foul-smelling drainage that is grayish in color

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

laxatives potassium supplements **corticosteroids antihypertensive drugs

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

serous purulent **serosanguineous sanguineous

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?

"As soon as the infection clears, your surgeon will staple the wound closed." **"Your wound will heal slowly as granulation tissue forms and fills the wound." "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?" **"Do you experience incontinence?"

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 must wait 15 minutes between applications of cold therapy." "I can let this stay on my ankle an hour at a time." "I should keep this on my ankle until it is numb." **"I will put a layer of cloth between my skin and the ice pack."

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"This procedure can be safely preformed using clean technique if care is taken not to touch the wound." "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." **"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care for dressing changes?

**Increases the risk of infection by contaminating the wound Promotes coolness to the site, which further constricts blood flow Reduces itching to the wound as it is healing Causes an uncomfortable sensation to the client's skin

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 Stage III Stage IV Stage I

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

**The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse packs the wound cavity tightly with dressing material. The nurse uses wet-to-dry dressings continuously. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown.

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse fungal infection accompanied by pruritus Superficial contusion accompanied by pruritus **Diffuse dermatitis accompanied by pruritus Superficial abscess accompanied by pruritus

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

Notify the health care provider of the findings. Gently rub and massage the area to warm it up. **Discontinue the therapy and assess the client. Document the findings in the client's medical recor

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

Use clean technique to clean the wound. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. **Clean the wound from the top to the bottom and from the center to outside. Clean the wound in a circular pattern, beginning on the perimeter of the wound

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

Utilize the culture swab to obtain cultures from multiple sites. Stroke the culture swab on surrounding skin first. Cleanse the wound after obtaining the wound culture. **Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

**Assess the client's wound and vital signs. Administer the prescribed analgesic. Document the pain and vital signs. Notify the health care provider of the pain.

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 removing purulent drainage from the wound bed in order to accurately assess it removing excess drainage and wet tissue to prevent maceration of surrounding skin stimulating the wound bed to promote the growth of granulation tissue

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. **A Penrose drain promotes passive drainage into a dressing. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain is a closed drainage system that is connected to an electronic suction device.

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline an otic curette a small plastic ruler a sterile tongue blade lubricated with water soluble gel

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

wound left open for several days to allow edema to subside a large wound with considerable tissue loss allowed to heal naturally **a surgical incision with sutured approximated edges a wound healing naturally that becomes infected.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

**an obese woman with a history of type 1 diabetes a client whose breast reconstruction surgery required numerous incisions A client who is NPO (nothing by mouth) following bowel surgery a man with a sedentary lifestyle and a long history of cigarette smoking

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select?

Negative wound pressure therapy **Hydrocolloid Wet to dry Telfa