Skin integrity and wound care application questions

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply.

-The nurse makes more frequent checks of the skin of an older adult using a heating pad -the nurse fills an ice bag with small pieces of ice to about two -thirds full -the nurse covers a cold pack with a cotton sleeve to keep it in place on an arm

Which would be appropriate action(s) for the nurse to take when cleaning and dressing a pressure injury? Select all that apply.

-Use whirlpool treatments, if prescribed, until the injury is considered clean -keep the injury tissue moist and the surrounding skin dry -use a dressing that absorbs exudate but maintains a moist healing environment

A nurse is providing wound care for a client who has a pressure injury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options.

1.Give pain medication 2. Use nonsterile gloves 3.Remove old dressing 4.Apply sterile gloves 5.Cleanse the wound with normal saline 6.Apply wound covering

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs

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 (1053)

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 (1054)

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 (Serous is pale yellow and watery)

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound (1064)

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 caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair

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 (1084)

Which is not considered a skin appendage?

connective tissue

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?

subcutaneous tissue (stores fat for energy)

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 (1091)