Prep U Chapter 31: Skin Integrity and Wound Care

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

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

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?"

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include?

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

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 states, "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 wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?

"Steri-Strips will hold my wound together until it heals."

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 nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply.

Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. Change the dressing midway between meals. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

A nurse is caring for a client who had an appendectomy and has been readmitted for wound care. The incision has been opened by the primary care provider to allow for drainage. The wound is draining copious amounts of yellow exudate. Which type of dressing will the nurse apply to the wound? Select all that apply.

Antimicrobials Composites Alginates

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention?

Apply sterile dressings with normal saline over the protruding organs and tissue.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document?

Black classification

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?

Braden scale

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

Clean the wound from the top to the bottom and from the center to outside.

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

Corticosteroids

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?

Dehiscence of the wound

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?

Depth

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?

Fish

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

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

Hemostasis phase

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

Keep the swab and the inside of the culture tube sterile.

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 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?

Proliferation Phase

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 adheres to the wound bed. Which modification is most appropriate?

Reduce the time interval between dressing changes.

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

Soak in a warm bath for drainage

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II

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

Stage IV

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure injury?

Support the client from sliding in bed

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

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

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

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

True

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 considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down

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

a sterile, flexible applicator moistened with saline

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

a surgical incision with sutured approximated edges

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

dehiscence

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

impaired skin integrity related to open wound

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

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?

shearing force

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

"Very little scar tissue will form."

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?

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

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 critical care client

What is the most accurate definition of a wound?

a disruption in normal skin and tissue integrity

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 is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is:

to provide drainage for bile

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 the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

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

Secondary intention

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?

Tearing of a structure from its normal position

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

gauze