Skin integrity and wound care Prep U

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 not anything that you need to worry about." "Dehiscence is when a wound has partial or total separation of the wound layers." "Dehiscence is a total separation of the wound with protrusion of the viscera through it." "Dehiscence is the softening of tissue due to excessive moisture."

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

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." "Douching is recommended so that you are clean for the examination." "Plan to begin douching routinely immediately after your procedure." "The Pap procedure includes application of a douche."

"Do not douche for 24-48 hours before the procedure." (this can wash away diagnostic cells)

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?" "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?"

"Do you experience incontinence?"

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 has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

For which client would the application of a hydrocolloid dressing be most appropriate? A client with a sunburn affecting his back and torso A client who has a partial-thickness venous ulcer with moderate drainage A client whose surgical incision dehisced and became infected A client who has just undergone a cholecystectomy (gallbladder removal)

A client who has a partial-thickness venous ulcer with moderate drainage

An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor? The client's size limits his activity level. Adipose tissue is poorly vascularized. Obesity is linked to impaired white blood cell function. The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.

Adipose tissue is poorly vascularized.

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? avulsion abrasion incision laceration

An incision is a clean separation of skin and tissue with smooth, even edges.

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

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

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? Red classification Yellow classification Black classification Unstageable

Black classification

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? Infection of the wound Herniation of the wound Dehiscence of the wound Evisceration of the viscera

Dehiscence of the wound

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? Notify the surgeon STAT Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

Rotate the swab several times over the wound surface to obtain an adequate specimen.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? The nurse uses a safety pin to attach the pad to the bedding. The nurse covers the heating pad with a heavy blanket. The nurse places the heating pad under the client's neck. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

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

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To splint the area when engaging in activity To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing

To splint the area when engaging in activity

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Superficial, which may be pinkish or red with no blistering May vary from brown or black to cherry red or pearly white; bullae may be present A superficial partial-thickness burn, which can appear dry and leathery

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

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 a client who lifts himself up on his elbows a client who lies on wrinkled sheets a client who must remain on his back for long periods of time

a client sitting in a chair who slides down

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 client whose breast reconstruction surgery required numerous incisions a man with a sedentary lifestyle and a long history of cigarette smoking A client who is NPO (nothing by mouth) following bowel surgery

an obese woman with a history of type 1 diabetes

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely: first degree or superficial second degree or partial thickness third degree or full thickness fourth degree or fat layer

second degree or partial thickness

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document? serous sanguineous serosanguineous purulent

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? friction necrosis of tissue ischemia shearing force

shearing force

A client birthed twins via cesarean and is learning to care for her incision. Which teaching will the nurse include? "You only need a binder to hold your incision together." "It is important to keep your sutured incision clean." "Reinforced adhesive skin closures can be peeled off after 48 hours." "You will have staples in place for several weeks."

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

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? "This is normal tissue." "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing."

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

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

"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? 26.6°-33.8° C (80°-93° F) 18.3°-26.6° C (65°-80° F) 10°-18.3° C (50°-65° F) Below 10° C (below 50° F)

10°-18.3° C (50°-65° F)

A nurse is caring for clients on a medical-surgical unit. On the basis of known risk factors, the nurse understands that which client has the highest risk for developing a pressure injury? 35-year-old client who was admitted after a motor vehicle accident, is on a liquid diet, and has bilateral casts on the upper extremities 45-year-old client who has cancer, is receiving chemotherapy, is incontinent, and is being admitted with leukopenia 65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest 70-year-old client with Alzheimer disease who wanders the nursing unit using a walker and refuses to sit and eat meals

65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest

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? Size Depth Tunneling Direction

Depth

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown? Implement a 2-hour repositioning schedule Perform passive range-of-motion exercises Massage skin surfaces daily, especially areas under pressure and bony prominences Frequently orient client to place and situation

Implement a 2-hour repositioning schedule

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple is removed. Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision.

Stop removing staples and inform the surgeon

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

True

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 I stage II stage III stage IV

stage III

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 check and empty the drain every 6 hours." "I will squeeze the chamber and apply the cap to maintain negative pressure." "I will apply a dressing at the end of the drain to catch any drainage." "I will alternate between positive and negative pressure every 2 hours."

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

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate? " The condition is hard to cure." "You will likely experience periods of increased skin outbreaks and periods of remissions." "You will have this disease for life." "Your personal health habits will dictate how well you handle this condition."

"You will likely experience periods of increased skin outbreaks and periods of remissions."

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain? If there is contamination of dirt and debris The event leading up to the trauma Staging the wound for assessment The status of the client's tetanus immunization

The status of the client's tetanus immunization

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon applying sterile dressings with normal saline over the protruding organs and tissue assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound

applying sterile dressings with normal saline over the protruding organs and tissue

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? preventing the client from sliding in bed lubricating the area with skin oil improving the client's hydration pulling the client up from under the arms

preventing the client from sliding in bed

he 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 I stage II stage III stage IV

stage IV

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 should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy." "I will put a layer of cloth between my skin and the ice pack." "I can let this stay on my ankle an hour at a time."

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

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? As a stage I pressure injury As a stage II pressure injury As a stage III pressure injury As a stage IV pressure injury

As a stage I pressure injury

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? Pasta salad Fish Banana Green beans

Fish

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 a gauze dressing precut halfway to fit around the IV line a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics

a transparent film

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

dehiscence.

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color

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 tape with eyelets transparent hydrocolloid

gauze

A skin infection caused by beta-hemolytic streptococci common in children is: acne vulgaris. impetigo. scabies. herpes.

impetigo.

The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care? cleansing the labia with scented soap soaking in a warm bath for drainage applying an ice pack to relieve pain exposing the area to a heat lamp

soaking in a warm bath for drainage

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. Draw the shape of the wound with a description. Measure the wound's length and width. Use a dry sterile applicator at a 90-degree angle to measure depth. Chart tunneling by using a quadrant approach to describe the location. Assess color, drainage, presence of pain, or complications.

Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications.

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order. Proliferation Hemostasis Inflammatory Maturation

Hemostasis Inflammatory Proliferation Maturation

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? Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Utilize the culture swab to obtain cultures from multiple sites. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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 for the use of antihypertensives assessing the client for claustrophobia assessing the wound for active bleeding assessing the client's mental status

assessing the wound for active bleeding

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 reinserting the protruding structures and applying a pressure dressing placing the client in the low Fowler position using sterile technique packing the wound with iodoform gauze

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