chapter 33

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? A. "Aim to take at least two showers daily to remove all microorganisms from the skin." B. "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." C. "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." D. "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? A. "Do you experience incontinence?" B. "How many meals a day do you eat?" C. "Do you use any lotions on your skin?" D. "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? A. "I should keep this on my ankle until it is numb." B. "I must wait 15 minutes between applications of cold therapy." C. "I will put a layer of cloth between my skin and the ice pack." D. "I can let this stay on my ankle an hour at a time."

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

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? A. "You will receive medication through this device." B. "Drainage will occur by gravity and capillary action." C. "It provides a way to remove drainage and blood from the surgical wound." D. "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 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? A. "This is normal tissue." B. "That is old clotted blood underneath the wound" C. "That is called undermining, a type of tissue erosion." D. "That is necrotic tissue, which must be removed to promote healing."

"That is necrotic tissue, which must be removed to promote healing."

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? A. "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." B. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." C. "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." D. "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."

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

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? A. "Your wound will heal slowly as granulation tissue forms and fills the wound." B. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." C. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." D. "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."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? A. "Very little scar tissue will form." B."This is a complex reparative process." C. "The margins of your wound are not in direct contact." D. "The surgeon will leave your wound open intentionally for a period of time."

A. "Very little scar tissue will form."

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply. A. Administer analgesia before changing the dressing around the drain, if needed. B. Perform hand hygiene and put on goggles before emptying the drain. C. Use a gauze pad to clean the drain outlet after emptying it. D. Leave the drain open for 5 to 7 minutes to ensure full drainage. E. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.

Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.

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

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? A. Allow the wound and intestinal contents to remain open to air. B. Apply saline solution-moistened gauze over the protruding area. C. Pack the wound with gauze pads and a dry sterile dressing. D. Inform the client that this is an expected occurrence and not to worry.

Apply saline solution-moistened gauze over the protruding area.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? A. Assess the client's wound and vital signs. B. Administer the prescribed analgesic. C. Notify the health care provider of the pain. D. Document the pain and vital signs.

Assess the client's wound and vital signs.

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity? A. Use soap liberally when bathing B. Check pressure points for redness after 60 minutes C. Clean perineal area daily but do not bathe full body on a daily basis D. Limit fluid intake

Clean perineal area daily but do not bathe full body on a daily basis

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? A. Use clean technique to clean the wound. B. Clean the wound in a circular pattern, beginning on the perimeter of the wound. C. Clean the wound from the top to the bottom and from the center to outside. D. 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.

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? A. contusion B. incision C. avulsion D. puncture

Contusion

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? A. Infection of the wound B. Herniation of the wound C. Dehiscence of the wound D. Evisceration of the viscera

Dehiscence of the wound

A child is brought to the clinic by a parent who states that the child has been at camp. The child has a rash on the face, arms, and legs and says that it itches severely. How will the nurse document the assessment findings? A. Diffuse dermatitis accompanied by pruritus B. Superficial contusion accompanied by pruritus C. Diffuse fungal infection accompanied by pruritus D. Superficial abscess accompanied by pruritus

Diffuse dermatitis 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? A. Discontinue the therapy and assess the client. B. Notify the health care provider of the findings. C. Document the findings in the client's medical record. D. Gently rub and massage the area to warm it up.

Discontinue the therapy and assess the client.

The nurse is performing an assessment of a client's full thickness pressure injury to the coccyx. The nurse observes that the wound bed is black and will consequently document what finding? A. Eschar B. Granulation tissue C. Gangrene D. Erythema

Eschar

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. A. Fingers with quick capillary refill B. Warm hand C. Decreased radial pulse D. Cyanosis E. No finger numbness or tingling

Fingers with quick capillary refill Warm Hand No finger numbness or tingling

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? A. Pasta salad B. Fish C. Banana D. Green beans

Fish

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

Increases the risk of infection by contaminating the wound

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? A. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. B. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. C. Carefully pick the crusts off the sutures with the forceps before removing them. D. Do not attempt to remove the sutures because the wound needs more time to heal.

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

The nurse is caring for a client with diarrhea caused by Clostridioides difficile. Which is the priority nursing assessment for this client? A. Monitor intake and output. B. Assess the coccyx area for blanching. C. Monitor the client for nausea. D. Assess mental status.

Monitor intake and output.

The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force? A. Preventing the client from sliding in bed B. Pulling the sheets to reposition the client every 2 hours C. Improving the client's hydration D. Gently pulling the client up from under the arms

Preventing the client from sliding in bed

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

Rotate the swab several times over the wound surface to obtain an adequate specimen.

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? A. Stage I B. Stage II C. Stage III D Stage IV

Stage II

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? A. Tearing of the skin and tissue with some type of instrument; tissue not aligned B. Cutting with a sharp instrument with wound edges in close approximation with correct alignment C. Tearing of a structure from its normal position D. Puncture of the skin

Tearing of a structure from its normal position

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? A. Scarring, sutures, and wound care B. Tetanus, infection, wound care, and pain control C. Prevention of recurring infection, ability to work, and wound care D. Tetanus, being able to walk, and scarring

Tetanus, infection, wound care, and pain control

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? A. The nurse works outward from the wound in lines parallel to it. B. The nurse uses friction when cleaning the wound to loosen dead cells. C. The nurse swabs the wound with povidone-iodine to fight infection in the wound. D. The nurse swabs the wound from the bottom to the top.

The nurse works outward from the wound in lines parallel to it.

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? A. If there is contamination of dirt and debris B. The event leading up to the trauma C. Staging the wound for assessment D. The status of the client's tetanus immunization

The status of the client's tetanus immunization

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? A. To splint the area when engaging in activity B. To ambulate using a cane or walker C. To remain in bed for the next 4 hours D. To turn the head away from the area whenever coughing

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

a client sitting in a chair who slides down

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? A. a newborn B. a client with cardiovascular disease C. an older client with arthritis D. a critical care client

a critical care client

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

a sterile, flexible applicator moistened with saline

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A. a large wound with considerable tissue loss allowed to heal naturally B. a surgical incision with sutured approximated edges C. a wound healing naturally that becomes infected. D. a wound left open for several days to allow edema to subside

a surgical incision with sutured approximated edges

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A. a surgical incision with sutured approximated edges B. a large wound with considerable tissue loss allowed to heal naturally C. a wound left open for several days to allow edema to subside D. a wound healing naturally that becomes infected.

a surgical incision with sutured approximated edges

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. a transparent film B. a gauze dressing precut halfway to fit around the IV line C. a dressing with a nonadherent coating D. a gauze dressing premedicated with antibiotics

a transparent film

A client's risk for the development of a pressure injury is most likely due to which lab result? A. albumin 2.5 mg/dL B. glucose 110 mg/dL C. hemoglobin A1C 7% D. sodium 135 mEq/L

albumin 2.5 mg/dL

The nurse would recognize which client as being particularly susceptible to impaired wound healing? A. an obese woman with a history of type 1 diabetes B. a client whose breast reconstruction surgery required numerous incisions. C. a man with a sedentary lifestyle and a long history of cigarette smoking D. A client who is NPO (nothing by mouth) following bowel surgery

an obese woman with a history of type 1 diabetes

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? A. contacting the surgeon B. applying sterile dressings with normal saline over the protruding organs and tissue C. assessing for impaired blood flow to the area of evisceration. D. monitoring for pallor and mottled appearance of the wound

applying sterile dressings with normal saline over the protruding organs and tissue

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? A. corticosteroids B. antihypertensive drugs C. potassium supplements D. laxatives

corticosteroids

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? A. exerting equal, but not excessive, tension with each turn of the bandage B. wrapping distally to proximally C. elevating and supporting the stump D. keeping the bandage free of gaps between turn

elevating and supporting the stump

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? A. fistula B. dehiscence C. hemorrhage D. evisceration

evisceration

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? A. foul-smelling drainage that is grayish in color B. copious drainage that is blood-tinged C. large amounts of drainage that is clear and watery and has no smell D. small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound? A. hemostasis B. inflammatory phase C. proliferation phase D. maturation phase

proliferation phase

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? A. removing dead or infected tissue to promote wound healing B. stimulating the wound bed to promote the growth of granulation tissue C. removing purulent drainage from the wound bed in order to accurately assess it D. removing excess drainage and wet tissue to prevent maceration of surrounding skin

removing dead or infected tissue to promote wound healing

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? A. stage I B. stage II C. stage III D. stage IV

stage II

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

use pillows to maintain a side-lying position as needed