Fundamentals Chapter 28 Wounds (Prep U)

The nurse is providing care for a client whose recent health deterioration has led to a nursing diagnosis of Risk for Impaired Tissue Integrity. What assessments should the nurse consequently perform? Select all that apply.

monitoring the client's fluid intake monitoring the client's nutritional status assessing the client's level of mobility assessing the client's bowel and bladder function

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?

nonblanchable redness

A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected?

full-thickness skin loss

The nurse should use extreme caution when applying heat therapy to which of the following clients?

a client who is unconscious

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

"It provides a way to remove drainage and blood from the surgical wound."

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other."

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."

The health care provider has ordered a cold ice bag to be applied to the wrist of a client with a sprain. The nurse will ensure that the cold application is at what temperature before application?

10°-18.3° C (50°-65° F)

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated and WBCs move into the wound.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

Local capillary pressure must be lower than external pressure.

Place the steps of using the device shown in the correct sequence.

Test the ice bag for leaks. Fill it one-half to two-thirds full of crushed ice or small cubes so it can be molded easily to the injured area. Eliminate as much air from the bag as possible. Pour water over the ice to provide slight melting. Leave the ice bag in place no more than 20-30 minutes. Allow the skin and tissue to recover for at least 30 minutes before reapplying.

What observation should the nurse make about a client's open wound if the wound is healing by third intention?

The wound edges are widely separated and brought together with closure material.

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record?

a separation of skin and tissue in which the edges are torn and irregular

A client's risk for the development of a pressure injury is most likely due to which lab result?

albumin 2.5 mg/dL

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

foul-smelling drainage that is grayish in color

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence.

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

hydrocolloid dressing

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

incision

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 is preparing to change the dressing on an elderly client's sacral wound that developed after a prolonged period of immobility prior to admission. Which action should the nurse perform while performing an aseptic change of this client's dressing?

performing hand washing before the dressing change and after removing the existing dressing

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should the nurse prioritize in order to minimize the client's chance of skin breakdown?

repositioning the client on a regular basis

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?

transparent film

A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?

undermining

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?

use pillows to maintain a side-lying position as needed

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 nurse assessing a client's diabetic ulcer notes the color of the wound's base. Which color would the nurse interpret as indicating a healthy wound with adequate circulation?

pink

The nurse educator on a hospital's acute medical unit has created a document encouraging nurses to use cold applications when appropriate to clients' plans of care. What benefits of cold application should the educator cite?

prevention of swelling

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?

"I will squeeze the chamber and apply the cap to maintain negative pressure."

A nurse is caring for a client who has undergone a below-the-knee amputation of the left leg. The surgeon is preparing to remove the initial surgical dressing and asks the nurse to obtain dressings and elastic bandages in preparation for removal. The nurse understands that which statement best explains the rationale for using the elastic bandages?

They provide light support to the area.

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

stage IV

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?

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

A client has a fissure on her finger due to chafing. The client asks, "How long will it be painful?" The nurse explains that the inflammation phase will last:

3 days.

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 promotes passive drainage into a dressing.

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen?

Impaired Skin Integrity related to open wound

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?

Risk for Infection

In consultation with a wound care nurse, a nurse has included wound irrigation in the nursing care plan of a client. What characteristic of the client's wound would justify the use of irrigation during the wound care regimen?

There is debris on the client's wound bed but granulation has begun to form.

The older adult client reports back pain, and an aquathermia heating pad has been prescribed for comfort. What actions will the nurse perform to provide a safe application of heat therapy for this client? Select all that apply.

assess the client's skin prior to the application of heat ensure that the aquathermia unit contains water to the appropriate level

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?

assessing the wound for active bleeding

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

cleanse with a new gauze for each stroke

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

corticosteroids

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and:

covering the wound area with sterile towels moistened with sterile 0.9% saline.

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?

evisceration

The nurse has collected blood from a client for laboratory analysis. Which dressing will the nurse select to cover the site from which the blood was drawn?

gauze

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?

hemostasis phase

A nurse is caring for a client who has recently undergone repair of a ventral hernia. What situations should the nurse assess for that may increase the risk for delay in surgical wound healing? Select all that apply

insufficient protein and vitamin C intake weak tissue and muscular support due to obesity distention of the abdomen from accumulated intestinal gas

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

mechanical debridement

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?

period during which the wound undergoes changes and maturation

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.

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?

proliferation phase

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

proliferation phase

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply.

provide incontinent care every 2 hours and as needed turn the client every 2 hours when the client is in bed encourage the client to take fluids every 2 hours

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and has adhered to the wound bed. Which modification is most appropriate?

reducing the interval between dressing changes

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 nurse is using the Braden Scale to determine a client's risk for pressure injuries. What criteria will the nurse assess? Select all that apply.

sensory perception nutrition ability friction

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is 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 type should the nurse document?

serosanguineous

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

shearing force

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound?

stage II pressure injury

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 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 are the appropriate nursing responses? 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."

A client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment?

"Do not douche for 24-48 hours before the procedure."

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

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

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?

"I will restrict my diet to fats and carbohydrates."

A client birthed twins via cesarean and is learning to care for her incision. Which teaching will the nurse include?

"It is important to keep your sutured incision clean."

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice?

It is appropriate to use clean technique during this procedure.

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:

a laceration.

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 in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

The nurse is preparing to change a large abdominal dressing in which blood and drainage is expected. In addition to gauze, which dressing supply will the nurse gather to take in the client's room?

adhesive strips with eyelets

A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?

tertiary intention

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

assisting the client in moving to prevent strain on the suture line

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?

transparent

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?

biosurgical debridement

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 nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply.

covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position using sterile technique

The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage?

figure-of-eight turn

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

figure-of-eight turn

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

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

notify the physician and prepare for surgery

Which processes are responsible for restoring integrity of the skin and damaged tissues in the care of a client with an open wound? Select all that apply.

resolution regeneration scar formation

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

secondary intention

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 is this?

secondary intention

The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care?

soaking in a warm bath for drainage

The client twisted his ankle while hiking in an isolated area. The client reports pain and is unable to bear weight on the ankle. A nurse who is present has conducted an assessment and recommended the client rest and elevate the leg while waiting for rescue. The nurse is applying to the ankle a commercially prepared ice pack that contains a chemical. What precautions would the nurse employ when applying cold therapy to the client's ankle? Select all that apply.

squeeze the nonfrozen chemical pack to activate assess the client's ankle skin frequently ask the client about numbness and pain related to the cold therapy place a cloth between the ice pack and the skin

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?

stage III pressure injury

A group of nursing students is reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which as healing by primary intention?

surgical incision