Unit 2 Chapter 29 Skin Integrity & Wound

A nurse administers an analgesic medication to a patient with a stage IV pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic?

30 minutes after administration

The nurse is caring for a patient who has undergone ankle surgery. The primary health care provider places a Jackson-Pratt device in the patient. Which nursing action by the nurse indicates a need for further teaching?

Places the container above the level of the wound

After assessing the wound of a patient, the nurse orders a wound culture. Which findings in the patient necessitated this intervention? Select all that apply.

Presence of a foul odor in the wound, Presence of purulent drainage from the wound, Presence of high amount of drainage from the wound

While assessing a patient who has a sacral pressure ulcer, the nurse finds that it is a stage II pressure ulcer. Which finding in the patient led the nurse to this conclusion?

Presence of a pink wound bed

The edges of a patient's appendectomy incision are approximated, and no drainage is noted. Which type of healing would be applied?

Primary intention

A nurse is teaching student nurses about the inflammatory response to an injury. Arrange the events in the order of their occurrence in a response to injury.

1- Rapid vasodilation at site of injury 2- Accumulation of fluid at site of injury 3- Formation of exudate at site of injury 4- Formation of granulation tissue

The nurse understands that the healing process of a full-thickness wound occurs in three phases. Arrange the phases of wound healing in the correct order.

1-inflammatory phase 2-proliferative phase 3-maturation

A 36-year-old man is admitted to the hospital following a motor vehicle accident. He has sustained multiple injuries on the forehead, right elbow, and left knee. On his forehead, there is a full-thickness loss of skin. The patient is given first aid and is treated with antibiotics. Arrange the phases of the healing process in appropriate order.

1.Inflammatory phase 2.Proliferative phase 3.Maturation phase

Which phrase describes a hydrocolloid dressing?

A dressing that forms a gel that interacts with the wound surface

The nurse is caring for a patient with a pressure ulcer. As part of the wound treatment, the nurse applies a wet dressing and removes it after it partially dries. Which characteristics are true about this method of wound treatment? Select all that apply.

A form of mechanical debridement, Avoided with a clean granulating wound, Helps in the removal of viable as well as devitalized tissue

The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which patients would be at increased risk of wound dehiscence? Select all that apply.

A malnourished patient, An obese patient, A patient with wound infection

A nurse is changing the dressing of a patient with a drain placed at the surgical site. The nurse notices that the collecting device has minimal drainage, which is much less than expected. Which suspicion does the nurse have based on this observation?

Blockage in the drainage tube

A nurse works in a long-term care unit. Which patients would be at high risk of developing pressure ulcers? Select all that apply.

An immobile patient with excessive wound drainage, A comatose patient, A patient with urinary incontinence, A patient with spinal cord injury

A long-term care facility encourages nurses to assess patients at risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the facility using for risk assessment of pressure ulcer development?

Braden Scale

An elderly patient with hemiparalysis had an incontinent episode, and the nurse is called to help the patient. Which steps does the nurse take to ensure proper skin care when cleaning? Select all that apply.

Apply moisture barrier ointment, Use a cleanser specifically for incontinence care or a mild, pH-neutral soap to clean the skin.

A patient presents to the emergency room with severe injuries. A nurse notices that the wound on the abdomen is so deep that the liver was eviscerated. Which prompt actions does the nurse take in such a case? Select all that apply.

Assess the patient for symptoms of shock, Contact the surgical team for emergency surgery, Place sterile towels soaked in saline over the wound.

A nurse is caring for a 37-year-old male who had abdominal surgery 1 day ago. Upon examining the incision, the nurse notices a purulent exudate has formed around the incision site. Which component does a purulent exudate consist of?

Bacteria

Which terms are used to describe impaired skin integrity related to prolonged, unrelieved pressure on a body part? Select all that apply.

Bedsore, Pressure sore, Pressure ulcer, Decubitus ulcer

When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

The nurse is caring for an elderly patient. During the assessment the nurse finds that the patient is susceptible to developing a decubitus ulcer. Which interventions would the nurse follow to prevent decubitus ulcer in this patient? Select all that apply.

Change the patient's position once every 2 hour, Prevent the patient's inner knees from pressing onto each other, Avoid placing the patient in positions that increase stress on bony prominences.

A patient with multiple fractures has casts that make it difficult to move voluntarily. A nurse notices red skin in the spinal area that blanches on applying pressure. Which measures does the nurse take to decrease the risk of development of pressure ulcers in this patient? Select all that apply.

Check the skin around the casts regularly for any signs of impaired skin integrity, Take care to avoid friction injuries during repositioning, bathing, or transferring of the patient, Use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements.

A 56-year-old hemiplegic patient lives in a long-term care facility. On examination, the nurse notices a pressure injury on the skin over his sacrum. Which factors may influence the development of bed ulcers in this patient? Select all that apply.

Chronic immobility can cause pressure injuries, Edema of the skin can cause pressure injuries, Dehydration of the body can cause pressure injuries.

The nurse instructs the trainee nurse to clean a patient's open-wound drainage. The trainee nurse cleans the wound in a horizontal motion, away from the drain. After cleansing the wound, the nurse applies drain sponges, sterile 4×4s, and an absorbent pad over the wound. Which action of the trainee nurse indicates the need for additional teaching?

Cleaning the wound in a horizontal motion

Which description best fits that of serous drainage from a wound?

Clear, watery plasma

Which stratum is the outermost layer of the patient's epidermis?

Corneum

A nurse observes a wound with intermittent suturing. What is the defining characteristic of intermittent suturing?

Each suture is tied and knotted individually.

Which nursing intervention would prevent venous stasis in a patient who has a lower limb wound?

Elevating the patient's leg for 30 minutes

The primary health care provider instructs the nurse to apply a bandage on a patient's injured leg. The nurse finds that the patient is anxious. Which nursing action would be taken first in this situation?

Explain the procedure to the patient.

The nurse makes an introduction and explains the procedure of wound care to the patient. The nurse then performs hand hygiene and checks the patient's treatment plan. Which specific intervention facilitates the patient's cooperation with wound care?

Explaining the wound care procedure

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.

A nurse is managing wound care for a patient with a stage III pressure ulcer on the elbow. The nurse cleans the area and removes all the dead, nonviable tissue from the wound. Which term is used to describe this process?

Debridement

Which process is described as the removal of devitalized tissue from a wound?

Debridement

The nurse is making rounds with the primary health care provider, who prescribes cold therapy. Which adaptation is the effect of cold therapy?

Decreased pain

A nurse obtains an air mattress for a patient who is at risk for impaired skin integrity. Which feature is an advantage of the air mattress?

Distributes body weight over a larger area

Which process occurs during the proliferative phase of wound healing in a patient?

Granulation tissue formation

The nurse is caring for a bedridden patient. During the physical examination, the nurse observes that the patient has intact, nonblistered skin with nonblanchable erythema at the sacral area. Which stage of pressure injury does the nurse suspect in the patient?

I

Which stage of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and pain?

I

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

Ice bag

The nurse is caring for a postsurgical patient. During a follow-up visit, the nurse finds that the patient has an infection at the surgical site. Which findings are consistent with the nurse's conclusion? Select all that apply.

Increase in pain, Increase in drainage, Elevation in temperature

A patient is admitted with a stage II pressure ulcer. Which characteristics of a pressure ulcer is the nurse likely to find during a wound assessment?

It has a red-pink wound bed without slough.

The patient has a stage III pressure ulcer. Which findings are characteristic of this type of pressure ulcer? Select all that apply.

It has full-thickness tissue loss, The subcutaneous fat may be visible, The bone, tendon, or muscle is not exposed.

Which statement is true about wet/damp-to-dry dressings for mechanical debridement of a wound?

It should be only moist, not wet, when applied.

During the follow-up visit after an appendectomy, the patient reports a popping sensation at the site of the surgical suture. The nurse finds that there is excessive drainage from the wound. Which interventions would the nurse follow for this patient? Select all that apply.

Moisten gauze with sterile normal saline and cover the wound, Notify the primary health care provider about the patient's condition.

The registered nurse is preparing a care plan for a patient with severe wounds. Which duties does the registered nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Observation of changes in skin integrity, Observation of changes in dietary intake, Measurement of the patient's body temperature

How does the nurse classify a stab wound based on skin integrity and the depth of the wound?

Open, full-thickness

The nurse applies a bandage to a patient's hand. Which signs would the nurse assess in the patient after application of the bandage? Select all that apply.

Pallor, Paresthesia, Pulselessness

A patient has serosanguineous drainage from a wound. Which description is characteristic of serosanguineous drainage?

Pink to pale red fluid

Which factor increases the risk of wound infection?

Reduced local tissue defenses

Which clinical finding is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

Reduction of stress on the abdominal incision

Which factor does the Braden Scale evaluate for?

Risk factors that place the patient at risk for skin breakdown

The nurse is caring for a patient who has a leg wound after an accident. During the follow-up visit, the nurse finds a foul odor and increased drainage at the site of the wound with necrotic tissue. Which type of debridement does the nurse expect the primary health care provider to prescribe?

Sharp

A 37-year-old patient has come to the clinic after sustaining an abrasion while gardening. Which characteristics of this type of wound is the nurse likely to find on assessment? Select all that apply.

Superficial, Appears weepy

A nurse is attending to a patient who is bedridden after a prolonged illness. The patient has darkly pigmented skin, which makes it difficult for the nurse to detect pressure ulcers. Which characteristics will alert the nurse about the possibility of developing pressure ulcers? Select all that apply.

The color remains unchanged when pressure is applied, The circumscribed area of intact skin may be warmer or cooler than the surrounding area, Skin may differ in firmness (either softer or firmer).

The nurse assesses a patient's abdominal wound and finds that the wound is in the proliferative phase of healing. Which changes in the wound might have led the nurse to this conclusion? Select all that apply.

The wound contracts to reduce the area that requires healing, The wound is filled with granulation tissue, There is reepithelialization of the wound surface.

A nurse is caring for a group of patients with wounds that are healing by primary intention. The nurse is attending to which types of wounds? Select all that apply.

Traumatic approximated wound, Surgical incision

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. Which stage best defines this patient's pressure ulcer?

Unstageable

A nurse assesses an older adult patient admitted to the hospital after a fall. Which assessment findings place the patient at higher risk of developing pressure ulcers? Select all that apply.

Urinary incontinence, Immobilization due to a leg fracture, Impaired sensory perception

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

Using an incontinence cleaner, followed by application of a moisture barrier ointment

The nurse performs debridement for a patient who has a wound on the hand. After the process, the patient reports pain and bleeding at the site of the wound. Which form of debridement had the nurse used in the patient?

Wet/damp-to-dry dressing

The primary health care provider has recommended vacuum-assisted therapy (VAC) to a patient to treat a diabetic ulcer. During VAC, the alarm suddenly starts beeping. Which possible cause would the nurse assess to identify the reason for the alarm?

Whether there is an air leak in the dressing

The nurse is caring for a patient who has undergone an appendectomy. During the follow-up visit, the nurse finds that the patient is coughing continuously. Which risks does the nurse suspect in the patient? Select all that apply.

Wound dehiscence, Wound evisceration

When obtaining a wound culture to determine the presence of a wound infection, from where would the specimen be taken?

Wound after it has first been cleaned with normal saline