Wound Prep-U

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 will put a layer of cloth between my skin and the ice pack." rationale: The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them?

"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation." Rationale: Most common bony prominences are the coccyx and sacrum. A pressure injury can appear in less than 2 hours. Most pressure injuries develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.

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?

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

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

"Very little scar tissue will form."

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other."

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."

The client cut his leg on a gardening tool several days ago and is being seen for an infected wound. The nurse is going to obtain a culture of the wound and then re-dress the wound. What are the steps, in order, for the nurse to obtain the wound culture and re-dress the wound? Arrange the following steps in the correct order

1. Remove the soiled dressing wearing clean gloves. 2. Clean the wound, wearing sterile gloves and using sterile supplies. 3. Dry the surrounding tissue with gauze. 4. Insert the culture swab deep into the wound, wearing clean gloves. 5. Using a different pair of gloves, place a clean dressing on the wound. Rationale: Since this is an acute wound it requires sterility.

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?

A Penrose drain promotes passive drainage into a dressing. rationale: The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply.

An infant's skin and mucous membranes are injured easily and are subject to infection.

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated and WBCs move into the wound.

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity?

Clean perineal area daily but do not bathe full body on a daily basis

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

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

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps.

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?

Depth Rationale: Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.

A home care nurse is visiting an older adult client. During the visit, the client's spouse sustains a minor thermal injury when cooking. The nurse intervenes, doing which of the following first?

Flush the area with copious amounts of cool water. Rationale: The nurse should flush the burned area with copious amounts of cool water. If done quickly, this action halts the burning process by speeding heat dissipation. It also helps to relieve pain. Remove any of the client's clothing and jewelry in the affected area because clothing and metal can retain heat. If clothing sticks to the burned area, cut around it, rather than pull it, which may traumatize underlying burned tissues. Avoid ointments and home remedies because they can complicate burn healing.

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen?

Impaired Skin Integrity related to open wound

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Penrose drain

The nurse would recognize which of these devices as an open drainage system?

Penrose drain Rationale: A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems.

When measuring the size, depth, and wound tunneling of a client's stage IV pressure injury, what action should the nurse perform first?

Perform hand hygiene.

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?

Risk for Infection Rationale: Clients who are taking corticosteroid medications are at high risk for delayed healing and wound complications such as infections. Corticosteroids decrease the inflammatory process, which may in turn delay healing.

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?

Stage II

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

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 20-30 minutes, assessing it regularly.

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

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

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

The nurse works outward from the wound in lines parallel to it. A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.

When the nurse is caring for a client with an open wound, which characteristic should be observed if the wound heals by primary intention?

The wound edges are directly next to each other. If the wound is to heal by primary intention, the wound edges are directly next to each other. Because the space between the wound edges is so narrow, only a small amount of scar tissue forms. If the wound edges are widely separated, leading to a more time-consuming and complex reparative process, then it is described as healing by secondary intention. With tertiary intention healing, the wound edges are widely separated and are later brought together with some type of closure material; the wounds may require a drainage device to promote quick healing.

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

A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe the client's wound?

a clean separation of skin and tissue with smooth, even edges

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

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

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 Rationale: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

The nurse should use extreme caution when applying heat therapy to which of the following clients?

a client who is unconscious Corticosteroids, pain sensitivity, and venous ulcers are not contraindications to the use of heat therapy.

What is the most accurate definition of a wound?

a disruption in normal skin and tissue integrity

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:

a laceration.

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record?

a separation of skin and tissue in which the edges are torn and irregular

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?

a sterile, flexible applicator moistened with saline rationale: An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.

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

a surgical incision with sutured approximated edges

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 7-year-old is brought to a health care facility after a fall from a swing. The nurse notes that surface layers of the skin have been scraped away. How should the nurse document this wound?

abrasion Rationale: An abrasion is an open wound in which the surface layers of the skin are scraped off. An incision can be described as a clean separation of skin and tissue with smooth, even edges. A laceration is described as a separation of skin and tissue in which the edges are torn and irregular. A puncture is an opening in the skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object. Ulceration is a shallow crater in which skin or mucous membrane is missing.

The nurse is preparing to change a large abdominal dressing in which blood and drainage is expected. In addition to gauze, which dressing supply will the nurse gather to take in the client's room?

adhesive strips with eyelets

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

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

applying sterile dressings with normal saline over the protruding organs and tissue Rationale: The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

assisting the client in moving to prevent strain on the suture line administering pain meds on a p.r.n. and regular basis prevent scar formation so it doesn't limit joint movement telling the client that a mild fever is a normal response Rationale: The proliferative phase of wound healing begins within 2 to 3 days of the injury. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations. Pain medication assists with the pain and not with the wound healing process. Fever is not a normal response. A scar will occur later in the wound healing process and usually does not limit the joint movement.

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?

biosurgical debridement In biosurgical debridement, fly larvae are used to clear the wound of necrotic tissue. This is accomplished by an enzyme the larvae releases. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, as in surgical debridement.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

cleanse with a new gauze for each stroke rationale: The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside.

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?

contusion (bruise) Rationale: A contusion is an injury to soft tissue, so this is what the nurse expects to see on the basis of the teacher's description of the incident. A puncture involves an opening in the skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripping of the surface layers of skin. In an avulsion injury, large areas of skin and underlying tissues have been stripped away.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

corticosteroids rationale: Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

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 placing the client in the low Fowler position using sterile technique

A nurse applies an aquathermia pad on the back of a client with arthritis. What is the expected action that will occur with this application of heat?

dilated peripheral blood vessels rationale: Heat dilates peripheral blood vessels, helping to dissipate heat from the body and to increase blood flow to the area. This increases the supply of oxygen and nutrients to the area and reduces venous congestion. Heat applications accelerate the inflammatory response, promoting healing.

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?

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?

elevating and supporting the stump Rationale: The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

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?

evisceration

The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage? The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

figure-of-eight turn Rationale: The figure 8 is good for joints. The circular turn is used primarily to anchor a bandage. The circular turn starts a spiral turn, a figure-of-eight turn, and a recurrent bandage. The spiral turn is useful for the wrist, fingers, and trunk. A recurrent bandage is used for fingers, the head, and residual limbs after amputation.

Which type of wound drainage should alert the nurse to the possibility of infection?

foul-smelling drainage that is grayish in color

A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected?

full-thickness skin loss

A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected? eschar formation

full-thickness skin loss Rationale: A stage IV pressure injury is characterized by the extensive destruction associated with full-thickness skin loss. At stage II, the skin breaks open, wears away, or forms an ulcer or blister, which is usually tender and painful. Slough or eschar may be present on some parts of the wound bed in stage IV but not always. Skin pallor occurs in stage I.

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

gauze Rationale: Transparent dressings are used to protect intravenous insertion sites. Hydrocolloid dressings are used to used keep a wound moist. Adhesive strips with eyelets are used to secure a gauze dressing that needs frequent changing.

A health care provider orders a dressing to cover a newly developed partial-thickness wound with minimal drainage. What would be the best type of dressing for this wound?

hydrocolloid dressing rationale: Hydrocolloid dressings are used for partial- and full-thickness wounds with minimal drainage. Saline-moistened dressings are often used with chronic wounds and pressure wounds. Montgomery straps are recommended to secure dressings on wounds that require frequent dressing changes, such as wounds with increased drainage. Foam dressings are recommended for chronic wounds.

A physician uses sutures during the surgery on a client at a health care facility. What are sutures?

knotted ties that hold an incision together Rationale: Staples are wide metal clips that form a bridge to hold two wound margins together. A bandage is a strip or roll of cloth wrapped around a body part. Open drains are tubes that provide pathways for drainage toward the dressing.

When treating a client for a sprained ankle, the nurse wraps the client's ankle in a bandage. What is the purpose of wrapping the client's ankle in a bandage?

limits movement in the wound area maintains a moist environment protects the wound from further injury holds the medication in place

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

mechanical debridement

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

notify the physician and prepare for surgery

A nurse is caring for a client with a puncture wound in the proliferation phase of the wound repair process. Which description reflects this phase of the wound repair process?

period during which new cells fill and seal a wound Resolution is the process by which damaged cells recover and reestablish their normal function. Remodeling, which follows the proliferation phase, is the period during which the wound undergoes change and maturation.

A client at a health care facility who underwent an appendectomy says to the nurse that he feels like something has "given way." On inspecting the surgical wound, the nurse notes pinkish drainage on the dressing. What intervention should the nurse perform in this case?

positioning the client to put the least strain on the operated area

Which condition is an indication for the use of negative pressure wound therapy?

pressure injuries Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure injuries; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin.

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention.

The spouse of a client limps into the emergency department and states, "I stepped on a nail and didn't have shoes on. Now I can barely walk." What type of injury does the nurse anticipate?

puncture

A nurse is assisting a physician who is using the sharp debridement technique at the bedside of a client at a health care facility. What is the purpose of sharp debridement?

removes necrotic tissue from healthy area of a wound In the sharp debridement technique, necrotic tissue is removed from a healthy area of a wound with the use of sterile scissors, forceps, or other instruments. This method is preferred if the wound is infected, because it helps the wound heal quickly and well. The procedure is done at the bedside, or in the operating room if the wound is extensive. Enzymatic debridement involves the use of topically applied chemical substances that break down and liquefy wound debris. Autolytic debridement, or self-dissolution, is a painless natural physiologic process that allows the body's enzymes to soften, liquefy, and release devitalized tissue. Mechanical debridement involves physical removal of debris from a deep wound.

Which processes are responsible for restoring integrity of the skin and damaged tissues in the care of a client with an open wound?

resolution regeneration scar formation Rationale: The nurse should understand that the integrity of the skin and damaged tissues is restored through resolution (the process by which damaged cells recover and reestablish their normal function), regeneration or cell duplication, and scar formation, which is the replacement of damaged cells with fibrous tissue. Leukocytosis is increased production of white blood cells. Phagocytosis is the process by which white blood cells consume pathogens, coagulated blood, and cellular debris.

A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound?

secondary intention

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

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?

serosanguineous

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as: 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?

serosanguineous rationale: Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

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?

shearing force

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound?

stage 2 pressure injury

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 3

The 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 IV

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections?

thorough hand hygiene

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?

transparent film Rationale: The transparency film allows visualization of the IV site, is self-adhesive, and protects against contamination.

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 Rationale: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?

white blood cells, debris, bacteria