Ch.36 Skin Integrity and Wound Care

6. The nurse is discussing strategies with the unlicensed assistive personnel (UAP) for bathing a client with dementia. Which strategies would be appropriate for the client? Select all that apply. 1. Cover the client as much as possible. 2. Sing or talk to the client. 3. Complete the bath as quickly as possible. 4. Be organized. 5. Expect the client to protest—finish quickly.

6. Answer: 1, 2, and 4. Rationale: Moving quickly may agitate the client (option 3). Protesting, screaming, and crying are not normal. Stop the bath and approach again later (option 5). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-8.

7. The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client. Which action indicates that the nurse needs to discuss additional teaching with the UAP? 1. Uses a clean portion of the washcloth for each stroke 2. Wipes from the pubis to the rectum 3. Uses clean gloves 4. Does not retract the foreskin

7. Answer: 4. Rationale: It is important to retract the foreskin to remove the smegma that collects under the foreskin and can cause bacterial growth. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 33-1.

1. A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client? 1. Totally dependent (+4) 2. Moderately dependent (+3) 3. Semidependent (+2) 4. Independent (0)

1. Answer: 3. Rationale: The client fits the descriptors for a semidependent functional level (see Table 33-2). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 33-3

10. The client is complaining of shortness of breath. His respirations are 28 and labored. The bed is currently in the flat position. The nurse puts the bed in which position? 1. Fowler's 2. Semi-Fowler's 3. Trendelenburg 4. Reverse Trendelenburg

10. Answer: 1. Rationale: Fowler's is a semisitting position that should ease the client's breathing. The head of the bed (HOB) in semi-Fowler's is lower (option 2). The HOB is lowered in the Trendelenburg position (option 3). Although the HOB is raised in the reverse Trendelenburg position, it is a straight tilt and may not be as comfortable as Fowler's (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 33-13.

2. The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client? 1. Presence of pain 2. Condition of the skin 3. Gag reflex 4. Range of motion

2. Answer: 3. Rationale: The client will be positioned in a side-lying position with the head of the bed lowered because the client is at risk for aspiration. The absence of the gag reflex lets the nurse know that the client has no natural defense (cough) and is at a higher risk for aspiration. All other answers are assessments more appropriate prior to bathing the client. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 33-4

3. A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin? 1. Soak her feet frequently. 2. Use a nonperfumed lotion. 3. Apply foot powder. 4. Avoid knee-high elastic stockings.

3. Answer: 2. Rationale: A lotion will help moisten the skin. Perfumed lotions contain alcohol, which is drying to the skin. Soaking the feet for a long time or frequently also causes dry skin (option 1). Applying foot powder is appropriate to prevent or control unpleasant foot odor (option 3). Elastic stockings may decrease circulation (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-15c.

4. The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client's hearing aid? 1. Turn the hearing aid off. 2. Soak the hearing aid in soapy solution to clean it. 3. Turn the volume all the way up. 4. Remove the batteries.

4. Answer: 1. Rationale: Turn off the hearing aid. Option 2 is incorrect because an in-the-ear hearing aid is cleaned with a damp cloth. Option 3 is incorrect; make sure the volume is turned all the way down because a too loud volume is distressing. Check that the battery is in the hearing aid; do not remove the batteries (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-15h

5. The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client? 1. Open bed in low position 2. Occupied bed in low position 3. Closed bed in high position 4. Surgical bed in high position

4. Answer: 1. Rationale: Turn off the hearing aid. Option 2 is incorrect because an in-the-ear hearing aid is cleaned with a damp cloth. Option 3 is incorrect; make sure the volume is turned all the way down because a too loud volume is distressing. Check that the battery is in the hearing aid; do not remove the batteries (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-15h

8. The nurse is planning a presentation on oral health at an intergenerational community center. Which statements will be important to include? Select all that apply. 1. Using a bottle during naps and bedtime can cause dental caries in a toddler. 2. Schedule a visit to the dentist when your child is ready to go to school. 3. It is important for parents to supervise a child's brushing of their teeth. 4. Most older adults have dentures and don't need to worry about oral care. 5. Older adults are at risk for periodontal disease.

8. Answer: 1, 3, and 5. Rationale: The developmental level warrants supervision. If the bottle is given during naps or bedtime, the solution has continuous contact with the toddler's teeth. The first visit to the dentist should occur between the ages of 2 and 3 (option 2). More than 50% of older adults have their own teeth (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 33-4.

9. The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates a need for further teaching? 1. "I am going to use a mirror to check my feet." 2. "I enjoy walking barefoot around the house." 3. "I will file my nails." 4. "I will increase the time that I wear new shoes each day."

9. Answer: 2. Rationale: The client needs to avoid walking barefoot because that could cause injury that may result in an infection. Also, neurologic impairment is likely as a result of the diabetes, which may result in decreased sensation. The client would be unaware of an injury. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 33-4

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. Offer the client a warm beverage (herbal tea)

A. CORRECT: Cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. B. An abdominal binder can help prevent, not treat, a wound evisceration. C. Do not handle or apply pressure to any exposed organs or tissues, because these actions increase the risks of trauma and perforation. D. CORRECT: This position minimizes pressure on the abdominal area. E. Keep the client NPO in anticipation of the surgical team taking them back to the surgical suite for repair of the evisceration

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst

A. CORRECT: Expect the client to have pain and tenderness at the wound site with an incisional infection. B. CORRECT: Expect the client to have fever and chills with an incisional infection. C. CORRECT: Expect the client to have reddened or inflamed wound edges with an incisional infection. D. Expect the client to have purulent drainage with an incisional infection. E. Do not expect changes in thirst as an indication of an incisional infection.

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

A. CORRECT: Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. B. Sutured surgical incisions heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. C. Unless the bone edges have pierced the skin, a casted bone fracture is an injury to underlying structures and does not require healing of the skin. D. Lacerations sealed with tissue adhesive heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. E. CORRECT: Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.

A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed.

A. CORRECT: Slightly elevate the head of the client's bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. B. Deep tissues can be traumatized when massaging the skin over bony prominences. C. Cornstarch and powder can abrade the client's sensitive skin and increase the risk for aspiration. D. CORRECT: Have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas. E. Reposition the client at least every 2 hr. Frequent position changes are important for preventing skin breakdown, but every 3 hr is not frequent enough

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Extremes in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care

A. The client is not at either extreme of the age spectrum. B. CORRECT: Diabetes mellitus is a chronic illness that places additional stress on the body's healing mechanisms. C. CORRECT: Hgb is essential for oxygen delivery to healing tissues, and this client's Hgb level is low. D. CORRECT: A BMI of 17.1 indicates that the client is underweight and, therefore, malnourished. Deficiencies in essential nutrients delay wound healing. E. There is no indication that there have been any breaches in aseptic technique during wound car

Proper technique for performing a wound culture includes which of the following? 1. Cleansing the wound prior to obtaining the specimen 2. Swabbing for the specimen in the area with the largest collection of drainage 3. Removing the crusts or scabs with sterile forceps and then culturing the site beneath 4.Waiting 8 hours following a dose of antibiotic to obtain the specimen

Answer: 1 Rationale: Wound culture specimen should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms (option 2). An appropriate specimen can be found can be obtained without causing the client the discomfort of debriding (option 3). One systemic antibiotics have begun, the interval of following a dose will not significantly affect the concentration of the wound organism (option 4).

The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide? 1. Wash the area with soap and hot water at every brief change. 2. Apply a petroleum-based cream to the area after cleaning. 3. Wipe the skin with an alcohol-free barrier film agent after cleaning. 4. Keep the client in bed on absorbent pads until the area clears.

Answer: 3 Rationale: Cleansing should be done with a mild cleansing agent and warm water, so (option 1) is not appropriate. Petroleum-based creams are now thought to offer poor overall skin protection and to interfere with incontinence brief absorption (option 2). Keeping the client in bed to treat this area is not necessary and may lead to problems with immobility (option 4)

You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury (Select all that apply) A. A 19 year old female who is a quadriplegic. B. A 35 year old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint. C. A 55 year old female who has controlled diabetes and is ambulating three times a day. D. A 76 year old male with an elevated ammonia level and is excessively sweaty. E. A 45 year old with a Braden Scale score of 8

The answer are A, B, D, and E. The only patient not at risk for a pressure injury is the patient in option B. Remember altered sensory perception, any type of moisture issue (incontinence, sweating etc.), immobility, poor nutrition, altered mental status (high ammonia level can cause confusion and drowsiness), Braden scale score less than 9 are all risk factors for a pressure injury.

While performing a skin assessment on a patient who is immobile, you note a purplish black area on the patient's left heel. The skin is intact. On palpation the site feels heavy and spongy. You suspect this may be? A. Stage 1 pressure injury B. Deep-tissue injury C. Stage 4 pressure injury D. Stage 2 pressure injury

The answer is B. Deep-tissue injuries present as purplish or blackish areas over skin that is intact. The fatty tissue below is injured. Also, they may look like a black blistered area and may feel heavy or squishy

You're educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury? A. There is full loss of skin tissue that can extend to the muscle, bone, or tendon. B. A hallmark of a stage 3 pressure injury is that the skin will be intact but it not blanch. C. The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue. D. The wound edges will never roll away (epibole) as with a stage 2 pressure injury.

The answer is C. This is the only correct statement about a stage 3 pressure injury.

How would you as the nurse stage a wound containing obscured, full-thickness skin and tissue lost: A. Stage 1 B. Stage 3 C. Stage 2 D. Unstageable E. Stage 4

The answer is D. This pressure injury is unstageable. Note the slough and eschar in the wound bed. As the nurse you are unable to assess the depth of the wound, therefore, it is currently unstageable.

You have a new admission. While performing a head-to-toe assessment on your patient, you note the following wound (partial skin thickness) on the patient's right heel. You document this as a: A. Stage 1 Pressure Injury B. Stage 3 Pressure Injury C. Unstageable D. Deep-Tissue Injury E. Stage 2 Pressure Injury F. Stage 4 Pressure Injury

The answer is E. This represents a stage 2 pressure injury (formerly known as a pressure ulcer). The skin is visibly damaged and NOT intact with PARTIAL loss of the dermis. No subq (fatty tissue) is visible. These wounds may be opened with a superficial red/pink ulcer or may have the formation of an opened or closed blister

You're developing a plan of care for a patient who is at risk for pressure injury development. The patient is 75 years old and weighs 95 lbs. The patient is confused and has right and left leg contractures. In addition, the patient has a urinary tract infection and is incontinent of urine. The patient is on aspiration precautions and is ordered a honey thick liquid diet with pureed foods. Select all the nursing intervention you will include in the patient's plan of care to prevent a pressure injury: A. When feeding the patient keep the head of bed elevated at 45' degree and avoid elevating the foot of the bed. B. Apply barrier cream as needed to the skin daily. C. Turn the patient every 4 hours. D. Keep linens and gowns dry and wrinkle free. E. Use a wedge pillow for the right and left legs daily.

The answers are B, D, and E. Option A is wrong because when the patient is sitting up you want to prevent them from sliding down in the bed. This can cause friction and shear, which can lead to a pressure injury. Raising the foot of the bed when the HOB is elevated will help prevent the patient from sliding down. Option C is wrong because you will need to turn the patient every 2 hours NOT every 4 hours. Option E is beneficial for the leg contractures to prevent a pressure injury to the knees and ankles.

An 86 year old female patient is immobile and is in the right lateral recumbent position. As the nurse you know that which sites below are at most risk for pressure injury in this position? (Select all that apply) A. Sacral B. Patella C. Ankle D. Ear E. Elbow F. Hip G. Heel H. Shoulder

The answers are: B, C, D, F, and H. The right lateral recumbent position is where the patient is positioned on their right side. Therefore, the ankle, ear, hip, knee, and shoulders are sites where a pressure injury can occur.