Ch 32: Skin Integrity and Wound Care (1)

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? pg. 1055

preventing the client from sliding in bed

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. pg. 1046

- Fingers with quick capillary refill - No finger numbness or tingling - Warm hand

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? pg. 1116-1121

Assess the client's wound and vital signs.

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 best action by the nurse at this time? pg. 1087

Discontinue the therapy and assess the client.

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? pg. 1063

foul-smelling drainage that is grayish in color

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? pg. 1112-1115

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

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? pg. 1080

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

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? pg. 1050

"Very little scar tissue will form."

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? pg. 1045

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

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? pg. 1058

As a stage I pressure injury

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? pg. 1096-1100

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

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? pg. 1053

Dehiscence of the wound

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? pg. 1082

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

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? pg. 1055

a client sitting in a chair who slides down

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? pg. 1107

a sterile, flexible applicator moistened with saline

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? pg. 1048

a surgical incision with sutured approximated edges

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? pg. 1054

removing dead or infected tissue to promote wound healing

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? pg. 1053

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

The nurse in the postanesthesia care unit (PACU) is assessing a new client who has just undergone abdominal exploratory laparotomy. Which response should the nurse prioritize after noting the SaO2 is 95% (0.95), blood pressure is 128/80 mm Hg, cardiac monitor is showing rare premature atrial contractions (PAC), and drainage on abdominal dressing is approximately 5 cm × 3 cm of pinkish drainage along the lower edge of the dressing? pg. 973

apply additional dressing, especially over the lower edge where drainage is occurring

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? pg. 1048

incision