226 Exam 1 PrepU Q's

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 when a wound has partial or total separation of the wound layers." (Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. p.1053)

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." (After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples. Reinforced adhesive skin closures are not strong enough to hold this type of wound together. p.1108)

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?

105°F to 109°F (40.5°C to 43°C) (The nurse should set the external heating pad in the 105°F to 109°F (40.5°C to 43°C) range, which is physiologically effective and comfortable for the client. Lower temperatures are not as effective, and higher temperatures may cause damage to the underlying skin and tissues. p.1121-1124)

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

Assess the client's wound and vital signs. (First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed. p.1116-1121)

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. (Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth. p.1096-1100)

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?

Dehiscence of the wound. (Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents. p.1053)

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?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. (If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing. p.1082)

The nurse is caring for an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help detect the potential for pressure injury? Select all that apply.

Nutritional status Mental status Skin moisture Sensory perception (The client has blood clots that could potentially travel to the lungs (thromboembolism), so the client needs to be on strict bed rest until treated for the condition and determined safe to ambulate. Stages of pressure injuries are used after there is a break in the skin's integrity, and the nurse is examining the client for potential risks for developing a pressure injury in this case. Nutritional status is important to assess to determine if skin has adequate nutrients to replace damaged or dead cells daily. In older adults, the first clue of an infection—fluid and electrolyte imbalance—is often a change in the mental status, and all these factors can influence the client not adequately moving in bed and increase pressure on the bony prominences. Skin moisture needs to be assessed because excessively dry or moist skin will break down easier than skin with a normal amount of moisture. Sensory perception is important to assess because if the client cannot feel light touch or painful stimuli, the client may not recognize lying in one position too long, which leads to increased pressure on tissues and damage to the skin. p.1093-1095)

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?

Removing dead or infected tissue to promote wound healing. (Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration. p.1054)

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:

Second degree or partial thickness. (Partial-thickness burns may be superficial or moderate to deep. A superficial partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good example. Moderate to deep partial-thickness burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present. The full-thickness burn appears dry and leathery. p.1057)

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. (This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent. p.1063)

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 stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling. p.1056)

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. (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. p.1091)

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. (Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery. p.1073)

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?

scraping off of surface layers of skin. (An abrasion involves stripping of layers on the skin's surface. Therefore the nurse anticipates seeing an abrasion on the basis of the description of the incident. An incision involves a clean separation of skin and tissue with smooth, even edges. An avulsion has stripped-away large areas of skin and underlying tissues, leaving bone and cartilage exposed. A puncture is a skin opening caused by a sharp, pointed object. p.1057)