Chapter 28 PrepU Timby

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.

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?

"I will restrict my diet to fats and carbohydrates."

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

"Do you experience incontinence?"

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?

"I will squeeze the chamber and apply the cap to maintain negative pressure."

A client birthed twins via cesarean and is learning to care for her incision. Which teaching will the nurse include?

"It is important to keep your sutured incision clean."

The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What are the appropriate nursing responses? Select all that apply.

"Medical maggots are sterilized before they are introduced to the wound." "The choice regarding whether to have or decline this treatment is yours." "I understand your concern; let's talk further about your thoughts about this treatment."

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."

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?

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

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.

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

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."

A client has a fissure on her finger due to chafing. The client asks, "How long will it be painful?" The nurse explains that the inflammation phase will last:

3 days

A nurse is caring for clients on a medical-surgical unit. On the basis of known risk factors, the nurse understands that which client has the highest risk for developing a pressure injury?

65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

Apply saline solution-moistened gauze over the protruding area.

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

Blood clotting is initiated and WBCs move into the wound.

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy. Which interventions should the nurse follow to apply the T-binder? (Select all that apply.)

Fasten the crossbar around the waist. Pass the tails through the client's legs. Pin the tails to the belt of the T-binder.

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 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?

Implement a 2-hour repositioning schedule

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

The nurse prevents and treats pressure ulcers in the at-risk population of immobile elders. Which of the following interventions will best treat a stage 1 pressure ulcer?

Off-load the area under pressure.

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document?

Presence of abnormalities that would impede healing

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.

Remove the soiled dressing wearing clean gloves. Clean the wound, wearing sterile gloves and using sterile supplies. Dry the surrounding tissue with gauze. Insert the culture swab deep into the wound, wearing clean gloves. Using a different pair of gloves, place a clean dressing on the wound.

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

Place the steps of using the device shown in the correct sequence.

Test the ice bag for leaks. Fill it one-half to two-thirds full of crushed ice or small cubes so it can be molded easily to the injured area. Eliminate as much air from the bag as possible. Pour water over the ice to provide slight melting. Leave the ice bag in place no more than 20-30 minutes. Allow the skin and tissue to recover for at least 30 minutes before reapplying.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

What observation should the nurse make about a client's open wound if the wound is healing by third intention?

The wound edges are widely separated and brought together with closure material.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

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

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

a client 68 years of age who is bedfast related to severe head trauma

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

a client who is unconscious

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

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

albumin 2.5 mg/dL

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

an obese woman with a history of type 1 diabetes

The nurse has delegated applying an elastic bandage with clips to the right knee of a 12-year-old client to the unlicensed assistive personnel (UAP). Which action will the nurse determine the UAP needs additional training?

applies wrap from proximal to distal direction

A client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues?

applying the dressing with a binder

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

assessing the wound for active bleeding

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

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

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

corticosteroids

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 postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply.

encourage the client to take fluids every 2 hours turn the client every 2 hours when the client is in bed provide incontinent care every 2 hours and as needed

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?

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?

figure of eight turn

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?

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

The nurse has collected blood from a client for laboratory analysis. Which dressing will the nurse select to cover the site from which the blood was drawn?

gauze

A group of nursing students is reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which as healing by primary intention?

surgical incision

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

hydrocolloid

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?

incision

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

The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?

oblique

A nurse is preparing to change the dressing on an elderly client's sacral wound that developed after a prolonged period of immobility prior to admission. Which action should the nurse perform while performing an aseptic change of this client's dressing?

performing hand washing before the dressing change and after removing the existing dressing

A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?

tertiary intention

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

preventing the client from sliding in bed

The nurse educator on a hospital's acute medical unit has created a document encouraging nurses to use cold applications when appropriate to clients' plans of care. What benefits of cold application should the educator cite?

prevention of swelling

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.

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

proliferation

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and has adhered to the wound bed. Which revision to the nursing care plan is most appropriate?

reducing the interval between dressing changes

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

Which best describes the proliferative phase, the third phase of the wound healing process?

reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization

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?

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

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

The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care?

soaking in a warm bath for drainage

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

stage II

The nurse assists in the surgical removal of eschar from a trochanter pressure ulcer revealing the bone and tendons. The nurse correctly stages this ulcer as what stage?

stage IV

A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?

undermining

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

An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor?

Adipose tissue is poorly vascularized.

In consultation with a wound care nurse, a nurse has included wound irrigation in the nursing care plan of a client. What characteristic of the client's wound would justify the use of irrigation during the wound care regimen?

There is debris on the client's wound bed but granulation has begun to form.

A nurse is caring for a client who has undergone a below-the-knee amputation of the left leg. The surgeon is preparing to remove the initial surgical dressing and asks the nurse to obtain dressings and elastic bandages in preparation for removal. The nurse understands that which statement best explains the rationale for using the elastic bandages?

They provide light support to the area.

The client twisted his ankle while hiking in an isolated area. The client reports pain and is unable to bear weight on the ankle. A nurse who is present has conducted an assessment and recommended the client rest and elevate the leg while waiting for rescue. The nurse is applying to the ankle a commercially prepared ice pack that contains a chemical. What precautions would the nurse employ when applying cold therapy to the client's ankle? Select all that apply.

squeeze the nonfrozen chemical pack to activate assess the client's ankle skin frequently ask the client about numbness and pain related to the cold therapy place a cloth between the ice pack and the skin

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 II 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 III

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?

stage III pressure injury

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

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the bandage?

supports the area around the wound