NUR 102 Ch. 36 Integumentary

Which of the following items are used to perform wound irrigation? Select all that apply. 1. clean gloves 2. sterile gloves 3. refrigerated irrigating solution 4. 60-mL syringe 5. forceps

Answer: 1,2,4. Rationale: To irrigate a wound, the nurse used clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be room or body temperature- certainly not refrigerated. Forceps may be used to remove or apply a dressing but are not required for irrigation.

Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. low-protein diet 2. Insomnia 3. lengthy surgical procedures 4. fever 5. sleeping on a waterbed

Answer: 1,3,4. Rationale: Risk factors for pressure ulcers include low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 5) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce the chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chances of skin breakdown.

Proper technique for performing a wound culture includes which of the following? 1. cleansing the wound prior to obtaining the specimen 2. swabbing for the specimen in the area with the largest collection of drainage. 3. removing crusts or scabs with sterile forceps and then culturing the site beneath 4. waiting 8 hours following a dose of antibiotic to obtain the specimen.

Answer: 1. Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client to discomfort of debriding. The nurse does not generally debride the wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a dose will not significantly affect the concentration of wound organisms.

Which of the following indicates proper use of a triangle arm sling? 1. the elbow is kept flexed at 90 degrees or more. 2. the knot is placed on either side of the vertebrae of the neck. 3. the sling extends to just proximal of the hand. 4. the sling is removed every 2 hours to check for circulation and skin integrity.

Answer: 2. Rationale: The knot of the triangle sling must be kept off the spinal processes because this would be uncomfortable and put unnecessary pressure on the vertebrae. The elbow should be flexed slightly less than 80 degrees (not >90 degrees as in option 1) so the hand is above the elbow to prevent dependent swelling. The sling must extend past the wrist in order to support the hand. Although the sling must be removed to check for circulation and skin integrity, every 2 hours (option 4) is unnecessarily frequent and impractical.

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is 1. Risk for Impaired Skin Integrity. 2. Impaired Skin Integrity. 3. Impaired Tissue Integrity 4. Risk for Infection.

Answer: 2. Rationale: This client has an actual impairment of the integrity of the skin due to the rash and the scratching so is no longer "at risk." Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected.

The nurse has applied an aquathermia pad to a client's back. After 15 minutes of treatment, the client says that the pack is no longer warm and asks the nurse to increase the temperature. How should the nurse evaluate this request? 1. since this client's thermal tolerance is higher than normal, increasing the temperature is necessary. 2. this client may be experiencing a rebound effect from the application of moist heat. 3. adaptation of the thermal receptors often results in the decreased sensation of warmth. 4. the aquathermia pad should be replaced with a standard hot pack.

Answer: 3. Rationale: After about 15 minutes of heat application, the thermal receptors adapt to the temperature increase and the sensation of warmth is diminished. Clients often request that the temperature be increased because they do not feel the same amount of heat. This can lead to burns. There is no evidence that this client has increased thermal tolerance or that the rebound effect is occurring.

The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide? 1. wash the area with soap and hot water at every brief change. 2. apply a petroleum-based cream to the area after cleaning. 3. wipe the skin with an alcohol-free barrier film agent after cleaning. 4. keep the client in bed on absorbent pads until the area clears.

Answer: 3. Rationale: Cleansing should be done with a mild cleansing agent and warm water, so option 1 is not appropriate. Petroleum-based creams are now thought to offer poor overall skin protection and to interfere with incontinence brief absorption (option2). Keeping the client in bed to treat this area is not necessary and may lead to problems with immobility (option4).

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1. alginate 2. dry gauze 3. hydrocolloid 4. no dressing is indicated

Answer: 3. Rationale: Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option1) are used for wounds with significant drainage; dry gauze (option2) will stick to new granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.

Which statement, if made by the client or family member, would indicate the need for further teaching? 1. "If a skin area gets red but then the red goes away after turning, I should report it to the nurse." 2. "Putting foam pads under my heels or other bony areas can help decrease pressure." 3. "If my father cannot turn himself in bed, I should help him change position every 4 hours." 4. "The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet."

Answer: 3. Rationale: Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires further teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin? 1. Keep the head of the client's bed at 30 degrees. 2. coat the client's back and buttocks with baby powder after bathing. 3. Use a turn sheet lifted by two staff members to move the client in bed. 4. Dust the linens with cornstarch each morning to allow for easier movement.

Answer: 3. Rationale: The head of the client's bed should be kept at less than 30 degrees elevation as much as possible (option1). Baby powder and cornstarch should not be used because they cause abrasive grit damage to tissues (option 2 & 4).

Which treatment would the nurse expect to institute for a patient with a Stage II pressure ulcer? a. a moisture-retentive dressing b. surgical debridement c. exposure to a heat lamp four times daily d. whirlpool treatment twice daily

Answer: A. Rationale: A moisture-retentive dressing provides a moist environment for wound healing.

Which intervention would the nurse expect to use for applying moist heat? a. sitz bath b. aquathermia pad c. hot water bag d. commercial hot pack

Answer: A. Rationale: A sitz bath is a moist heat application. All the other responses are examples of dry heat.

Which hospitalized patient is most at risk for a pressure ulcer? a. 70-yr-old patient with a fractured hip b. 45-yr-old woman recovering from gallbladder surgery c. 16-yr-old boy who suffered a spinal cord injury d. 50-yr-old patient who suffered a mild stroke

Answer: A. Rationale: An older patient with a fractured hip already has age-related skin changes that, coupled with some degree of immobility, make that person a likely candidate.

After a surgical incision, a patient often has an elevated body temperature and generalized malaise. These manifestations most often occur during which phase of wound healing? a. Inflammatory b. Primary c. Fibroplasia d. Maturation

Answer: A. Rationale: Systemic manifestations occur as a result of the inflammatory response to the altered skin and tissue integrity. Systemic manifestations do not usually continue into the fibroplasia and maturation phases of wound healing.

After initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer is classified as: a. Stage I b. Stage II c. Stage III d. Stage IV

Answer: B. Rationale: A stage II pressure ulcer is superficial and presents clinically as an abrasion, ulcer, or shallow crater.

The nurse assesses a stage III pressure ulcer manifested as: a. redness that persists when pressure is relieved b. an open lesion with subcutaneous tissue exposed c. a necrotic area extending through the fascia to bone d. a reddened area with an abrasion

Answer: B. Rationale: A stage III pressure ulcer is an open lesion that exposes subcutaneous tissue. Redness that persists is stage I; a reddened area that has an abrasion is stage II; and a necrotic area extending through the fascia to the bone is stage IV.

When assessing a patient at risk for pressure ulcer formation, which site would the nurse identify as being most common? a. occipital area b. sacrum c. sternum d. humerus

Answer: B. Rationale: All sites involve bony prominences, but the sacrum is one of the most common areas where pressure ulcers develop.

An older confused patient sits and slumps in her chair most of the day. She is most likely to develop a pressure ulcer because of: a. malnutrition b. shearing forces c. edema d. a chronic disease

Answer: B. Rationale: Sitting slumped in a chair for an extended period can easily result in shearing force, causing a pressure ulcer. Malnutrition, edema, and the presence of chronic disease may certainly be risk factors for the development of a pressure ulcer, but the most likely cause in this situation is shearing force.

A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. You immediately report this as: a. an overproduction of granulation tissue b. wound dehiscence with evisceration c. a normal response to a large wound d. an unknown complication

Answer: B. Rationale: The wound complications of dehiscence and evisceration are manifested by a wound that opens up and has viscera protruding.

When explaining about factors contributing to pressure ulcers, which factor would the nurse describe as key? a. moisture b. incontinence c. pressure d. malnutrition

Answer: C. Rationale: Pressure is a key factor contributing to a pressure ulcer. It interferes with circulation to the cell, resulting in cell death. Moisture, incontinence, and malnutrition predispose a patient to impaired skin integrity, making the skin more susceptible to injury.

Sara Liu, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, Sara says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a. pain b. impaired skin integrity c. disturbed body image d. disturbed thought processes

Answer: C. Rationale: Wounds cause emotional as well as physical stress.

Which action would be a priority in preventing a patient from developing a pressure ulcer? a. using waterproof material on the bed b. massaging any reddened area frequently c. using an air-inflated ring to relieve pressure on areas d. using a mild cleansing agent when cleansing the skin

Answer: D. Rationale: A mild cleaning agent is less irritating. The skin should be rinsed, if necessary for the product used, and dried thoroughly.

Which action is believed to be most useful in preventing wound infections? a. using sterile dressing supplies b. suggesting dietary supplements c. applying antibiotic ointment d. performing careful hand hygiene

Answer: D. Rationale: Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

During a dressing change, inspection of the wound reveals what appears to be reddish-pink tissue in the wound. The nurse interprets this as most likely indicating: a. a sign of infection b. eschar c. exudate d. granulation tissue

Answer: D. Rationale: Granulation tissue is new tissue composed of many small blood vessels, is pinkish red, and fills and open wound when it starts to heal.

Which term would the nurse use to document wound drainage that is thick, odorous, and green? a. Serous b. Sanguineous c. Serosanguineous d. Purulent

Answer: D. Rationale: Purulent drainage is the result of an infection and is thick, odorous, and colored.