Tissue Integrity
D
A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? A) foam B) alginate dressing C) hydrocolloid dressing D) semipermeable transparent film
C
A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A) partial-thickness burn B) stage 3 pressure ulcer C) surgical incision D) dehisced sternal wound
A
A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching? A) Pressure injury includes the location, stage, measurements, and condition of the wound bed and any drainage present B) Drainage from the pressure injury only needs to be documented if a foul odor is present C) If the pressure injury is healing as expected, documentation can be completed with every other dressing change D) Pressure injuries found on the mucous membranes should be documented as stage 1 pressure injuries
A, C, D, E
An older adult client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of this client? Select all that apply. A) heels B) ankles C) elbows D) sacrum E) back of the head F) greater trochanter
B
The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressings, the nurse assesses the surgical site. Which should be the nurse's initial action if the appearance shown in the figure is observed? A) document the findings B) apply a sterile nonadherent dressing C) redress the wound with a dry sterile dressing D) ask the client to cough to assess for protrusion of internal structures
D
The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? A) deep tissue injury B) stage 2 pressure ulcer C) stage 3 pressure ulcer D) stage 4 pressure ulcer
D
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A) tenderness when touched B) pink, shiny tissue with granular appearance C) serousanguineous drainage D) halo of erythema on the surrounding skin
B
A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A) Preventing the transfer of microorganisms to the nurse B) Keeping microorganisms from entering the wound C) Applying minimal pressure to the wound D) Keeping excess moisture from entering the wound
B
A client is admitted to the hospital with a partial-thickness skin loss and blister on the sacrum. The nurse should develop a plan of care for which stage of the pressure ulcer? A) Stage 1 ulcer B) Stage 2 ulcer C) Stage 3 ulcer D) Stage 4 ulcer
D
A client is being admitted to the hospital for treatment of acute cellulitis of the lower leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe the diagnosis. Which answer demonstrates the student's understanding of the diagnosis? A) it is an acute superficial infection B) it is an inflammation of the epidermis C) Staphylococcus is the cause of this epidermal infection D) this skin infection involved deep dermis and subcutaneous fat
B
A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? A) milk B) oranges C) bananas D) chicken
A
A nurse completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? A) a client who has a Braden Scale score of 9 B) a client who has a Braden Scale score of 23 C) a client who has a Braden Scale score of 12 D) a client who has a Braden Scale score of 15
B
A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect? A) a red incision site with a small amount of exudate B) a bright pink incision site that is absent of exudate C) a pale pink incision site with moderate amounts of exudate D) a white to silver incision site absent of exudate
D
A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity? A) cellulitis B) skin tears C) premature wrinkling D) dermatitis
C
A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound? A) hydrofiber B) alginate C) hydrogel D) transparent film
C
A nurse is caring for a client who has a dime-sized stage one pressure injury located on the sacrum. Which of the following dressing types should the nurse use? A) a hydrogel dressing B) a wet gauze dressing C) a transparent film D) an alginate dressing
C
A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that which of the following nutrients (in addition to protein) promotes wound healing? A) Vitamin B1 B) Calcium C) Vitamin C D) Potassium
C
A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage is three-fourths full. Which of the following actions should the nurse take? A) decrease the drainage suction force B) place the bulb on a flat surface and measure the amount of drainage C) empty and measure the drainage D) kink the tubing to prevent further drainage
A
A nurse is caring for a client who has a stage 2 pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A) Hydrocolloid B) Collagen C) Calcium alginate D) Proteolytic enzyme
C
A nurse is caring for a client who has a stage 3 pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A) obtain the prescribed irrigation solution B) don PPE C) check the client's pain level D) place a waterproof pad under the client's extremity
D
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perineal area. Which actions should the nurse take first? A) apply a fecal collection system B) apply a barrier cream C) cleanse and dry the area D) check the client's perineum
C
A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take? A) Ask the client to bear down and cough B) Ask another nurse to bring ice packs to apply to the wound C) Cover the client's wound with a sterile saline dressing D) Place the client in high-Fowler's position.
B
A nurse is caring for a client who is 2 days postoperative. Which of the following findings indicates the client is developing an infection? A) temperature 37.8C (100F) B) erythema at the incision site C) WBC count 9,000/mm^3 D) pain reported as a 6/10
D
A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A) clean the incision from bottom to top B) apply sterile gloves prior to opening dressing packages C) remove the tape by pulling away from the wound D) clean the drain site from center outward
B
A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? A) A client who has a lower extremity fracture and uses the overhead bed trapeze to move B) A client who is incontinent and is taking a prescribed diuretic C) A client who is NPO for surgery and is receiving IV fluids D) A client who has lung cancer and will be receiving their first radiation treatment
C
A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include? A) bathe daily with moisturizing soap B) apply antibacterial topical medication to the crusted exudate C) apply warm compresses to the affected area D) cover the affected area with snug-fitting clothing
C, E
A nurse is instructing a nursing assistant on how to prevent pressure ulcers for frail elderly clients. Which actions by the nursing assistant indicate understanding of the instructions? Select all that apply. A) maintains a cooler environment when bathing B) bathes and dries vigorously to stimulate circulation C) offers nutritional supplements and frequent snacks D) keeps the head of the bed elevated at 45 degrees E) turns the patient at least every 2 hours
B
A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis? A) hypertension B) increased blood glucose C) decreased WBC count D) increased BUN
A
A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity? A) the AP places the client in high-Fowler's position B) the AP places pillows under the client's lower extremities C) the AP feeds the client 80% of each meal D) the AP cleans and dries the client's perineum after each episode of incontinence
A
A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of the pressure injury? A) Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue B) Stage 3 pressure injury to the coccyx observed with a non-blanchable area of erythema C) Stage 3 pressure injury to the coccyx observed partial-thickness skin loss, wound bed pink and moist D) Stage 3 pressure injury to the coccyx observed with full-thickness skin loss, muscle and bone visible
A
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A) vitamin C and zinc B) vitamin D C) vitamin K and iron D) calcium
B
A nurse is planning care for an older adult client who is bedridden. Which of the following should the nurse include in the plan to prevent skin breakdown? A) firmly massage lotion into the client's skin B) tilt the client on their side at 30 degrees C) Slide the client to the edge of the bed to transfer D) Keep the head of the bed at 45 degrees when in the supine position
B
A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following should the nurse identify as an indication that the client understands medical asepsis? A) "I'll wrap the old dressing in a paper bag and put int in the trash" B) "I'll wash my hands before I remove the old dressing and again before putting on the new one" C) "I'll need to take a pain pill 30 mins before I change the dressing" D) "I'll wear sterile gloves when I apply the new dressing"
B
A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take? A) Obtain the culture using a clean cotton applicator B) Clean the wound with 0.9% sodium chloride C) Collect drainage from the area surrounding the wound D) Place the applicator in a dry vial until cultures are complete
B, E
A nurse is providing discharge teaching about wound care to a client who has a leg wound. Which of the following pieces of information should the nurse include in the teaching? Select all that apply. A) Use cotton balls to clean the infected areas B) Cleanse the wound with tap water C) Dry the leg wound after cleaning D) Microwave the cleaning solution before applying to the wound E) Discard soiled bandages in a moisture-proof bag
C
A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? A) be sure to keep the skin moist B) do not use pillows to support extremities C) flex the client's knees while in bed D) provide a firm mattress for the client
D
A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the clients indicates an understanding of an alginate dressing? A) the dressing will need to be changed every 24hr B) this type of dressing is used in small wounds with small amounts of drainage C) this dressing may develop a foul-smelling, yellow, gelatinous film on its underside as bacteria are trapped D) this type of dressing will need a secondary dressing for reinforcement
A
A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown? A) You should shift your weight off your buttocks at intervals throughout the day A) You should shift your weight off your buttocks at intervals throughout the day B) You should be sure your legs are placed on the floor prior to transferring C) Position yourself in the back of the wheelchair after transferring D) Lock your brakes when you are sitting in the wheelchair
D
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A) the wound edges are well-approximated B) the wound is closed at a later date C) a skin graft is placed over the wound bed D) granulation tissue fills the wound during healing
D
A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the rolling statement by the new nurse indicates an understanding of the teaching? A) the skin is the strongest during early childhood B) the epidermis pads internal organs and structures C) the subcutaneous layer of the skin contains cells that contribute to skin and hair color D) the skin assists in the regulation of body temperature
B
A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching? A) "I should consume a diet high in carbohydrates" B) "I should increase my protein intake" C) "I should include fruit and vegetables with every meal" D) I should avoid meat products"
B
A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the new nurse indicates an understanding of healing by secondary intention? A) this type of healing carries a lower risk of infection than others B) this type of healing begins in the wound bed with the generation of granulations tissue C) these wounds heal faster than those that heal by other processes D) these wounds require a dry wound bed in order for healing to occur
D
A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? A) Skin changes cause the synthesis of vitamin B to decrease with age B) The layers of the skin become detached with age C) Older adult clients have more moisture in the skin, placing them at risk for maceration D) The skin of older adults is thinner and has less subcutaneous padding over bony prominences
D
A patient has a blood-filled blister surrounded by tissue that is painful, mushy, and warm to the touch. How should the nurse classify this skin presentation? A) Stage 3 ulcer B) Stage 4 ulcer C) Unstageable D) Suspected tissue injury
A, E
A patient's leg wound is not healing as quickly as expected. What should the nurse do to determine the reason for the patient's poor healing? Select all that apply. A) Obtain a referral for a dietician B) Elevate the extremity on a pillow C) Increase the frequency of dressing changes D) Encourage increased independent movement E) Obtain an order for prealbumin and albumin levels
B
The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A) red, hard skin B) serous drainage C) purulent drainage D) warm, tender skin
C
The nurse notes that a patient has several lacerations over the coccyx area. Which finding most likely caused these lesions? A) heat B) pressure C) shearing D) moisture
D
The nurse notes that a patient's wound is weeping and edematous. In which phase of healing is the wound? A) maturation B) hemostasis C) proliferative D) inflammatory
B, C, E
The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage 3 pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which steps should the nurse include in the teaching plan? Select all that apply. A) applying a dry, sterile dressing B) cleansing the wound C) managing pain D) using cold water in the bath E) hand washing
A, C
The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates which interventions will be prescribed for the client? Select all that apply. A) Antibiotic therapy B) Cold compresses to the affected area C) Warm compresses to the affected area D) Intermittent heat lamp treatment 4 times a day E) Alternating hot & cold compresses
A,B,C,E
The nurse suspects that a patient is developing a complicated soft tissue bacterial infection. What assessment findings caused the nurse to come to this conclusion? Select all that apply. A) Pain B) Fever C) Tachycardia D) Muscle atrophy E) Low BP
