Week 11 PrepU

"Very little scar tissue will form."

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

"It provides a way to remove drainage and blood from the surgical wound."

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?

decubitus ulcer

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

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

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?

transparent

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

stage II

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?

albumin 2.5 mg/dL

A client's risk for the development of a pressure injury is most likely due to which lab result?

removing dead or infected tissue to promote wound healing

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

serosanguineous

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?

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

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?

The nurse works outward from the wound in lines parallel to it.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

surgical incision with sutured approximated edges

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

fish

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?

Figure of eight turn

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

a sterile, flexible applicator moistened with saline

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?

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

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?

"Reinforced adhesive skin closures will hold my wound together until it heals."

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

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?

Subcutaneous 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?

a rash related to a yeast infection.

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:

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

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?

an obese woman with a history of type 1 diabetes

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

To splint the area when engaging in activity

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

hydrocolloid dressing

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing?

Connective tissue

Which is not considered a skin appendage?

scraping off of surface layers of skin

A client comes to the emergency department after falling off a skateboard onto the sidewalk. Which assessment data, consistent with an abrasion, would the nurse expect to see?

Stop the sitz bath, call for help, and help the client to the toilet to sit down.

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action?

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

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

Assess the client's wound and vital signs.

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

to apply sunscreen when exposed to ultraviolet rays.

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

use pillows to maintain a side-lying position as needed

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?

biosurgical debridement

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?

A Penrose drain promotes passive drainage into a dressing.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

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

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

Serosanguineous

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

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

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

Stop removing staples and inform the surgeon

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?

Secondary intention

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

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

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

Dehiscence of the wound

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?

contusion

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

local capillary pressure must be lower than external pressure

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse?

milia.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

a client sitting in a chair who slides down

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?

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform?

Apply a skin protectant to the skin around the incision.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

evisceration

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

Hemostasis, Inflammatory, Proliferation, Maturation

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.

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

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?

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

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

Discontinue the therapy and assess the client.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the bestaction by the nurse at this time?

a critical care client

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?

elevating and supporting the stump

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

105°F to 109°F (40.5°C to 43°C)

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

A nurse places a drainage dressing around a drain insertion site. A nurse places a transparent dressing over a central venous access device insertion site. A nurse uses aseptic techniques when changing a dressing.

The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply.

"Do you experience incontinence?"

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

Off-load pressure from the heel.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

a teenager with multiple body piercings a client receiving radiation therapy a client with diabetes

Which clients would be considered at risk for skin alterations? Select all that apply.