NURS (FUNDAMENTAL): Ch 31 NCLEX Skin Integrity and Wound Care

A nurse is caring for a client who has a pressure ulcer on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-blue (RYB) Wound Classification System, which of the following classifications should the nurse document? a) Black classification b) Unstageable c) Yellow classification d) Red classification

a) Black classification

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? a) Clean the wound from the top to the bottom, and center to outside. b) Once the wound is cleaned, dry the area with an absorbent cloth. c) Use clean technique to clean the wound. d) Clean the wound from the bottom to the top, and outside to center.

a) Clean the wound from the top to the bottom, and center to outside.

Which is not considered a skin appendage? a) Connective tissue b) Hair c) Sebaceous gland d) Eccrine sweat glands

a) Connective tissue Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective 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) Laxatives c) Antihypertensive drugs d) Potassium supplements

a) Corticosteroids Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a) Document the findings and continue to monitor the patient. b) Administer antipyretics, as ordered. c) Increase the frequency of assessment to every hour and notify the patient's primary care provider. d) Increase the frequency of wound care and contact the primary care provider for an antibiotic order.

a) Document the findings and continue to monitor the patient. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

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

a) False

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which of the following is not one of these factors? a) Local capillary pressure must be lower than external pressure. b) The heart must be able to pump adequately. c) Arteries and veins must be patent and functioning well. d) The volume of circulating blood must be sufficient.

a) Local capillary pressure must be lower than external pressure.

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a) Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b) Draw the shape of the wound and describe how deep it appears in centimeters. c) Gently insert a sterile applicator into the wound and move it in a clockwise direction. d) Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

a) Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

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 the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize with this client's wound? a) Proliferation Phase b) Inflammatory Phase c) Maturation Phase d) Hemostasis

a) Proliferation Phase The wound description reveals a beefy red wound bed that bleeds easily. This is the proliferation stage and describes granulation tissue. Hemostasis is the initial phase that involves activation of platelets. The inflammatory phase involves white blood cells and macrophages entering the wound to remove debris from the wound. The maturation phase involves collagen remodeling and scar formation.

A nurse is documenting 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? a) Serosanguineous b) Serous c) Sanguineous d) Purulent

a) Serosanguineous

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) an otic curette c) a small plastic ruler d) a sterile tongue blade lubricated with water soluble gel

a) a sterile, flexible applicator moistened with saline

A client has developed blisters around the tape that secures the dressing. The nurse should: a) apply the dressing with a binder. b) use Montgomery straps. c) apply tape to the side of the blisters. d) apply skin barrier to protect skin.

a) apply the dressing with a binder. Bandages, binders, and stretch nets also can be used to hold gauze dressings in place.

Which type of wound drainage should alert the nurse to the possibility of infection? a) foul-smelling drainage that is grayish in color b) copious wound drainage that is blood-tinged c) drainage that appears to be mostly fresh blood d) large amounts of drainage that is clear and watery

a) foul-smelling drainage that is grayish in color

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? a) shearing force b) ischemia c) friction d) necrosis of tissue

a) shearing force A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. a) Use a sterile applicator to apply any ointment that is ordered. b) Clean the wound from top to bottom. c) Use a new gauze for each wipe of the wound. d) Avoid touching the wound bed, whether with gloves or forceps. e) Clean from the outside of the wound to the center.

a, b, c, d

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a) Serous drainage is composed of the clear portion of the blood and serous membranes. b) Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c) Bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d) Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e) Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f) Serosanguineous drainage can be dark yellow or green depending on the causative organism.

a, b, c, d Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

A nurse is providing wound care for a client who has a pressure ulcer on the right buttock. Which of the following is the correct order of nursing interventions the nurse should perform during this dressing change? a) Give pain medication b) Use nonsterile gloves c) Cleanse the wound with normal saline d) Remove old dressing e) Apply wound covering f) Apply sterile gloves

a, b, d, f, c, e The correct order for this dressing change is giving pain medication, applying nonsterile gloves to remove old dressing, removing old dressing, applying sterile gloves, cleansing the wound with normal saline, and applying a wound covering.

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a) Use standard precautions or transmission-based precautions when indicated. b) Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c) Clean the wound in full or half circles beginning on the outside and working toward the center. d) Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e) Clean to at least one inch beyond the end of the new dressing if one is being applied. f) Clean to at least three inches beyond the wound if a new dressing is not being applied.

a, b, e The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least one inch beyond the end of the new dressing, and (6) clean to at least two inches beyond the wound margins if a dressing is not being applied.

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.) a) A wound that requires wound cleaning and irrigation b) A wound with drainage that is a beige color c) A wound that reflects the color of normal granulation tissue d) A wound that is treated by using sharp, mechanical, or chemical dÉbridement e) A wound that is covered with thick eschar f) A wound that is characterized by oozing from the tissue covering the wound

a, b, f The nurse would document a wound that is characterized by oozing form the tissue covering the wound as a Y (yellow) wound. The nurse would document a wound that has beige colored drainage and a wound that requires wound cleaning and irrigation as Y (yellow) wounds. A wound that reflects the color of normal granulation tissue would be a R (red) wound. A wound that is covered with thick eschar would be documented as a B (black) wound. A wound that is treated by using sharp, mechanical, or chemical debridement would be documented as a B (black) wound.

In which situations has the nurse used a dressing properly? (Select all that apply.) a) A nurse places OpSite over a central venous access device insertion site. b) A nurse places Sof-Wick around a drain insertion site. c) A nurse places a transparent dressings over an ABD to help keep the wound dry. d) A nurse applies Telfa to a wound to keep drainage from passing through to a secondary dressing. e) A nurse places a Surgipad directly over an incision. f) A nurse uses appropriate aseptic techniques when changing a dressing.

a, b, f An OpSite helps to secure the device and is appropriate for a site with little drainage. The Sof-Wick absorbs drainage and protects the wound from contamination or injury. The nurse would not place a transparent dressing over an ABD pad. The nurse would use tape on the ABD pad. Drainage could be marked on the tape to determine any changes in drainage. The purpose of a Telfa is to not adhere to the wound, and allows drainage to pass through to a secondary dressing.

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a) Hemostasis occurs immediately after the initial injury. b) A liquid called exudate is formed during the proliferation phase. c) White blood cells move to the wound in the inflammatory phase. d) Granulation tissue forms in the inflammatory phase. e) During the inflammatory phase, the patient has generalized body response. f) A scar forms during the proliferation phase.

a, c, e Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking out of plasma and blood components into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change. a) Use sterile gloves. b) Ensure that negative pressure has been achieved. c) Place the drape to cover the wound and an additional 3 to 5 cm. d) Cut the foam to the shape and measurement of the wound. e) Cut a 2-cm hole in the drape. f) Apply a vacuum device to wound.

a, d, c, e, f, b The correct order for the application of negative pressure wound therapy is as follows: apply sterile gloves; cut the foam to the shape and measurement of the wound; place the drape to cover the wound and an additional 3 to 5 cm; cut a 2-cm hole in the drape; apply vacuum device to the wound; and ensure that negative pressure has been achieved.

Which best describes the third phase of the wound healing process: proliferative? a) is marked by vasodilation and phagocytosis as the body works to clean the wound b) Epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization. c) the onset of vasoconstriction, platelet aggregation, and clot formation d) The number of fibroblasts decreases, collagen synthesis is stabilized and collagen fibrils become increasingly organized, resulting in greater tensile strength of the wound.

b) Epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization. In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization.

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing? a) Green beans b) Fish c) Pasta salad d) Banana

b) Fish To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing.

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate? a) "Dehiscence is a total separation of the wound with protrusion of the viscera through it." b) "Dehiscence is when a wound has partial or total separation of the wound layers." c) "Dehiscence is not anything that you need to worry about." d) "Dehiscence is the softening of tissue due to excessive moisture."

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

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question? a) "How many meals a day do you eat?" b) "Do you experience incontinence?" c) "Do you use any lotions on your skin?" d) "Have you had any recent illnesses?"

b) "Do you experience incontinence?"

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains? a) A Penrose drain is a closed drainage system that is connected to an electronic suction device. b) A Penrose drain promotes drainage passively into a dressing. c) A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. d) A Penrose drain has a small bulblike collection chamber that is kept under negative pressure.

b) A Penrose drain promotes drainage passively into a dressing.

A client's risk for the development of a pressure ulcer is most likely due to which lab result? a) Sodium 135 mEq/L b) Albumin 2.5 mg/dL c) Glucose 110 mg/dL d) Hemoglobin A1C 7%

b) Albumin 2.5 mg/dL An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure ulcer. Hemoglobin A1C levels greater than 8% place the client at risk for the development of pressure ulcers due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure ulcers. Sodium of 135 mEq/L is normal and would not place the client at risk for the development of a pressure ulcer.

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? a) Tunneling b) Depth c) Direction d) Size

b) Depth

The nurse caring for client that had abdominal surgery 12 hours ago notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? a) Change the dressing. b) Document the findings. c) Notify the wound care nurse. d) Contact the physician.

b) Document the findings. The nurse should document the findings and continue to monitor the dressing. As it is a small amount of drainage, there is no need to contact the physician or the wound care nurse. The nurse should not change the dressing, as the dressing is still the surgical dressing and most often the surgeon will change the first surgical dressing within 24 to 48 hours.

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 of the following actions should the nurse perform in obtaining a wound culture? a) Utilize the culture swab to obtain cultures from multiple sites. b) Keep the swab and inside of the culture tube sterile. c) Cleanse the wound after obtaining the wound culture. d) Stroke the culture swab on surrounding skin first.

b) Keep the swab and inside of the culture tube sterile. The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surround the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? a) Irrigate the wound. b) Provide gentle cleansing of the wound. c) Débride the wound. d) Change the dressing frequently.

b) Provide gentle cleansing of the wound. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires débridement (removal) before the wound can heal.

A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain? a) Provides a sinus tract for drainage b) Provides drainage for bile c) Diverts drainage to the peritoneal cavity d) Decreases dead space by decreasing drainage

b) Provides drainage for bile

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) Stimulating the wound bed to promote the growth of granulation tissue b) Removing dead or infected tissue to promote wound healing c) Removing excess drainage and wet tissue to prevent maceration of surrounding skin d) Removing purulent drainage from the wound bed in order to accurately assess it

b) Removing dead or infected tissue to promote wound healing

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? a) Purulent b) Serosanguineous c) Serous d) Sanguineous

b) Serosanguineous

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? a) Stage I b) Stage II c) Stage IV d) Stage III

b) Stage II

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

b) Stage II A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.

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? a) Muscle layer b) Subcutaneous tissue c) Epidermis d) Dermis

b) Subcutaneous tissue The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.

A nurse is caring for a client who has an avulsion of her left thumb. Which of the following descriptions should the nurse understand as being the definition of avulsion? a) Cutting with a sharp instrument with wound edges in close approximation with correct alignment b) Tearing of a structure from its normal position c) Puncture of the skin d) Tearing of the skin and tissue with some type of instrument: tissue not aligned

b) Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edged in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

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

b) True A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract.

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

b) an obese woman with a history of type 1 diabetes

A nurse is caring for a client who has recently undergone hernial surgery. What are possible causes of complications with regard to surgical wounds? Select all that apply. a) compromised blood circulation b) weak tissue and muscular support due to obesity c) distension of the abdomen from accumulated intestinal gas d) insufficient protein and vitamin C intake e) Serous fluid accumulation prevents skin tissue approximation.

b, c, d The nurse should remember that insufficient protein and vitamin C intake, weak tissue, muscular support due to obesity, and distension of the abdomen from accumulated intestinal gas are the likely causes of surgical complications. Premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; or compromised tissue integrity from previous surgical procedures in the same area are some of the other causes of surgical complication. Compromised blood circulation and serous fluid accumulation that prevents skin tissue approximation are the factors that interfere with wound healing.

A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply. a) The patient takes time to think about her responses to questions. b) The patient's age of 86 years. c) Patient reports inability to control urine. d) A scheduled hip arthroplasty e) Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL). f) Patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure ulcer development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure ulcer development. Apathy, confusion, and/or altered mental status are risk factors for pressure ulcer development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure ulcer development.

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. a) a client who eats a diet high in vitamins A and C b) a client who is obese c) a client with a peripheral vascular disorder d) a 10-year-old client with a surgical incision e) a client who is taking corticosteroid drugs f) an older adult who is confined to bed

b, c, e, f There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure ulcer formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure ulcer development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client.

Which education points would the nurse use to explain the development of pressure ulcers to clients and how to prevent them? Select all that apply. a) "Generally, a pressure ulcer will not appear within the first 2 days in a person who has not moved for an extended period of time." b) "The skin can tolerate considerable pressure without cell death, but for short periods only." c) "Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." d) "The major predisposing factor for a pressure ulcer is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues." e) "Most pressure ulcers occur over the trochanter and calcaneus." f) "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation."

b, c, f Pressure ulcers usually occur over bony prominences. The skin can tolerate considerable pressure without cell death, but for short periods only. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation. Pressure ulcers can develop in a variety of locations where bony prominences are located. The most common are the coccyx and sacrum. A pressure ulcer can appear in less than 2 hours of time, depending on the factors present. Most pressure ulcers develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.

Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a client's wound? Select all that apply. a) Using clean technique, open the supplies and dressings and place the fine-mesh gauze into the basin, pouring the ordered solution over the mesh to saturate it. b) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. c) Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. d) Apply one dry, sterile gauze pad over the wet gauze, and then place an ABD pad over the gauze pad. e) Put on clean gloves and squeeze excess fluid from the gauze dressing before packing it tightly in the wound. f) Position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end.

b, c, f The nurse would position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. The nurse would carefully and gently remove the soiled dressings and use an adhesive remover to help remove the tape, if necessary. The nurse would gently press to loosely pack the wound, using forceps or cotton-tipped applications to press the gauze into all the wound surfaces.

A nurse assessing client wounds would document which examples of wounds as healing normally without complications? Select all that apply. a) incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes b) a wound that does not feel hot upon palpation c) a wound that takes approximately 2 weeks for the edges to appear normal and heal together d) The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. e) a wound with increased swelling and drainage that may occur during the first 5 days of the wound healing process f) a wound that forms exudate due to the inflammatory response

b, d, f The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. This would be a correct way to document a normally healing wound. A wound that does not feel hot upon palpation would be another example of correctly documenting a wound that has no complications. A wound that is warm to touch is not an abnormal finding. A wound that forms exudate due to the inflammatory response would be correct documentation of a normal finding.

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? a) "I can expect to have more discomfort in the area where the cold is applied." b) "I should expect more drainage from the incision after the ice has been in place." c) "I should see less swelling and redness with the cold treatment." d) "My incision may bleed more when the ice is first applied."

c) "I should see less swelling and redness with the cold treatment." The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

The nurse is caring for a client who has a heavy exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? a) Transparent film such as Tegaderm b) A hydrogel dressing such as Aquasorb c) An alginate dressing such as AlgiCell d) An antimicrobial dressing such as SilvaSorb

c) An alginate dressing such as AlgiCell

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a) A child's skin becomes less resistant to injury and infection as the child grows. b) An individual's skin changes little over the life span. c) An infant's skin and mucous membranes are easily injured and at risk for infection. d) In children younger than 2 years, the skin is thicker and stronger than in adults.

c) An infant's skin and mucous membranes are easily injured and at risk for infection. An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

The healthcare provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? a) Assess the client for claustrophobia. b) Assess for the use of antihypertensives. c) Assess the wound for active bleeding. d) Assess the client's mental status.

c) Assess the wound for active bleeding. Negative-pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed. NPWT is not considered for the use in the presence of active bleeding. The nurse needs to assess for the use of anticoagulants, not antihypertensives, because these can cause bleeding.

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) Evisceration of the viscera c) Dehiscence of the wound d) Herniation of the wound

c) Dehiscence of the wound Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

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 client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a) Evisceration b) Maceration c) Desiccation d) Necrosis

c) Desiccation

A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient 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

c) Disturbed Body Image Wounds cause emotional as well as physical stress.

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? a) Alginates b) Hydrogels c) Hydrocolloid dressings d) Transparent films

c) Hydrocolloid dressings Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small, partial-thickness wounds with minimal drainage.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. b) Do not attempt to remove the sutures because they need more time to heal. c) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. d) Pick the crusts off the sutures with the forceps before removing them.

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

A nurse is assessing a pressure ulcer 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? a) Stage IV b) Stage I c) Stage III d) Stage II

c) Stage III Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscles.

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer? a) Improve the client's hydration. b) Pull client up under the arms. c) Support the client from sliding in bed. d) Lubricate the area with skin oil.

c) Support the client from sliding in bed.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? a) The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. b) The nurse packs the wound cavity tightly with dressing material. c) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. d) The nurse uses wet-to-dry dressings continuously.

c) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.

A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient? a) The therapy is used to collect excess blood loss and prevent the formation of a scab. b) The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c) The therapy provides a moist environment and stimulates blood flow to the wound. d) The therapy irrigates the wound to keep it free from debris and excess wound fluid.

c) The therapy provides a moist environment and stimulates blood flow to the wound. Negative-pressure wound therapy (or topical negative pressure [TNP]) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record? a) Unintentional, full-thickness wound b) Intentional, full-thickness wound c) Unintentional, partial-thickness wound d) Intentional, partial-thickness wound

c) Unintentional, partial-thickness wound The child sustained an unintentional, partial-thickness wound. An unintentional wound is an accidental wound. A partial-thickness wound is characterized by all or a portion of the dermis remaining intact. A full-thickness wound is characterized by severing of the entire dermis, sweat glands, and hair follicles.

A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn? a) superficial, may be pinkish or red with no blistering b) may vary from brown or black to cherry red or pearly white; bullae may be present c) usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown d) also called a superficial partial-thickness burn, can appear dry and leathery

c) usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown

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. In which order should the nurse perform the following interventions? Arrange from first to last. a) Notify the physician immediately of the situation. b) Cover the exposed tissue with sterile towels moistened with sterile NSS. c) Place the patient in the low Fowler's position.

c, b, a Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position, cover the exposed tissue with sterile towels moistened with sterile NSS, and notify the physician immediately of the situation.

The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a) Enhanced healing due to the presence of sugars and proteins b) Delayed healing due to dead tissue present in the wound c) Decreased effectiveness of antibiotics against the bacteria d) Impaired skin integrity due to overhydration of the cells of the wound e) Delayed healing due to cells dehydrating and dying f) Decreased effectiveness of the patient's normal immune process

c, f Wound biofilms are the result of wound bacteria growing in clumps, imbedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Beitz, 2012). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate? a) "Allowing a scab to form would prevent us from observing the wound for signs of infection." b) "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." c) "You may be correct. I will check with your primary health care provider." d) "Wounds heal better when a moist wound bed is maintained."

d) "Wounds heal better when a moist wound bed is maintained."

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

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

Which action should the nurse perform when applying negative pressure wound therapy? a) Irrigate the wound thoroughly using normal saline and clean technique. b) Test the seal of the completed dressing by briefly attaching it to wall suction. c) Increase the negative pressure setting until drainage is brisk. d) Cut foam to the shape of the wound and place it in the wound.

d) Cut foam to the shape of the wound and place it in the wound. When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

The nurse observes the client for signs of Stage I pressure ulcer development, which is most likely to include which finding? a) Visible subcutaneous fat b) A shallow, open ulcer c) Exposed bone with eschar d) Nonblanchable redness

d) Nonblanchable redness A Stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A Stage III ulcer presents with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Stage IV ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a) Using sterile dressing supplies b) Suggesting dietary supplements c) Applying antibiotic ointment d) Performing careful hand hygiene

d) Performing careful hand hygiene Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

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 uses friction when cleaning the wound to loosen dead cells. b) The nurse swabs the wound from the bottom to the top. c) The nurse swabs the wound with povidone-iodine to fight infection in the wound. d) The nurse works outward from the wound in lines parallel to it.

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

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 ulcer? a) Elevate the head of the bed 90 degrees. b) Provide incontinent care every 4 hours as needed. c) Place a foot board on the bed. d) Use pillows to maintain a side-lying position as needed.

d) Use pillows to maintain a side-lying position as needed.

A nurse is developing a plan of care related to prevention of pressure ulcers for residents in a long-term care facility. Which action would be a priority in preventing a patient from developing a pressure ulcer? a) Keeping the head of the bed elevated as often as possible b) Massaging over bony prominences c) Repositioning bed-bound patients every 4 hours d) Using a mild cleansing agent when cleansing the skin

d) Using a mild cleansing agent when cleansing the skin To prevent pressure ulcers, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces? a) a client who lifts himself up on his elbows b) a client who lies on wrinkled sheets c) a client who must remain on his back for long periods of time d) a client sitting in a chair who slides down

d) a client sitting in a chair who slides down

The nurse is performing pressure ulcer assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure ulcer? a) an older client with arthritis b) a newborn c) a client with cardiovascular disease d) a critical care client

d) a critical care client

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 wound healing naturally that becomes infected. c) a wound left open for several days to allow edema to subside d) a surgical incision with sutured approximated edges

d) a surgical incision with sutured approximated edges Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue.

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) a gauze dressing premedicated with antibiotics b) a dressing with a nonadherent coating c) a gauze dressing precut halfway to fit around the IV line d) a transparent film

d) a transparent film Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings do not allow the nurse to visualize the site without partially or completely removing the dressing.