Chapter 29: wound

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first? a. Notify the provider. b. Notify the wound care nurse. c. Stop the procedure. d. Give the patient pain medication.

c. Stop the procedure. If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or preexisting. Then the nurse can determine what to do next based on the patient's response.

The nurse recognizes that cold therapy is contraindicated in which conditions? (Select all that apply.) a. Edema b. Shivering c. Bleeding d. Circulatory problems e. Advanced age

a. Edema b. Shivering d. Circulatory problems Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (this is a comfort concern). Bleeding is contraindicated in heat therapy. Advanced age would require frequent observation due to thin skin.

The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect? a. Stratum germinativum b. Epidermis c. Subcutaneous layer d. Stratum corneum

c. Subcutaneous layer The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

The nurse knows which description would be classified as a closed wound? a. A large bruise on the side of the face b. A surgical incision that is sutured closedterm-1 c. A puncture wound that is healing d. An abrasion on the leg

a. A large bruise on the side of the face In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin's surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing? (Select all that apply.) a. A patient who has diabetes. b. A patient with COPD. c. A patient with on bed rest who is repositioned. d. A patient who is obese and sweats excessively. e. A patient on long-term steroid therapy.

a. A patient who has diabetes. b. A patient with COPD. c. A patient with on bed rest who is repositioned. d. A patient who is obese and sweats excessively. e. A patient on long-term steroid therapy. Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin's ability to obtain required oxygen and nutrients, or diabetes, which affects not only the microvasculature, but also the skin's normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal, anti-inflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

The nurse is using the Braden scale to assess the patient's risk for a pressure ulcer. Which risk categories are associated with the Braden scale? (Select all that apply.) a. Activity b. Friction and shear c. Moisture d. Sensory perception e. Cognition

a. Activity b. Friction and shear c. Moisture d. Sensory perception The Braden scale ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The scale does not include cognition.

A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and would appropriately document which intervention? a. Change the hydrocolloid dressing daily. b. Change the hydrocolloid dressing every 3 to 5 days. c. Apply the hydrocolloid dressing over a dry, sterile dressing. d. Apply the hydrocolloid dressing over a normal saline-soaked dressing.

a. Change the hydrocolloid dressing daily. A hydrocolloid dressing contains hydroactive particles embedded in a polymer base that are softened by wound moisture and act as a protective gel over healing tissue. It is applied directly to the wound and needs to be changed every 3 to 5 days (or more frequently if drainage from the wound is excessive). It is not applied over a dry, sterile dressing or a normal saline-soaked dressing because it then would not be able to act as a protective gel.

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions would the nurse take in the care of the drain? Select all that apply. a. Check the drain for patency. b. Observe for bright red bloody drainage. c. Clamp the drain for 15 minutes every hour. d. Curl the drain tightly, and tape it firmly to the body.

a. Check the drain for patency. b. Observe for bright red bloody drainage. e. Maintain aseptic technique when emptying the drain. The nurse would check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse would monitor the drainage characteristics. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. A postoperative drain would not be curled tightly or obstructed in any way, such as with clamping. This could prevent the drain from functioning properly.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply. a. Contact the surgeon. b. Instruct the client to remain quiet. c. Prepare the client for wound closure. d. Document the findings and actions taken. e. Place a sterile saline dressing and ice packs over the wound. f. Place the client in a supine position without a pillow under the head.

a. Contact the surgeon. b. Instruct the client to remain quiet. c. Prepare the client for wound closure. d. Document the findings and actions taken. Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse would call for help, stay with the client, ask another nurse to contact the surgeon, and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client? a. Ensure that a sterile safety pin is through the drain. b. Measure the amount of drainage in a measuring container. c. Establish that the drain is at the prescribed amount of suction. d. Squeeze the suction device and close the port after emptying the drain.

a. Ensure that a sterile safety pin is through the drain. A Penrose drain is a soft, flat, flexible drain in which 1 end is placed in the wound or incision and the other end is outside the wound. It is an open drainage system that drains onto the skin surface or onto a dressing. It is not sutured in place and thus would have a sterile safety pin (or other device per agency procedure) inserted through it to prevent the drain from going all the way into the wound. Thus, option 1 is the correct option. Options 2, 3, and 4 are incorrect, as a Penrose drain is an open drainage system with no suction and it drains onto the skin or into a dressing, not into a collection container, so the amount of drainage cannot be measured in a measuring container.

An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. a. Heels b. Ankles c. Elbows d. Sacrum e. Back of the head

a. Heels c. Elbows d. Sacrum e. Back of the head When the client is lying supine, the heels, sacrum, and back of the head are all at risk, as are the elbows and scapulae. The greater trochanter and ankles are at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position.

The nurse recognizes that the cause of pressure ulcers includes which factors? (Select all that apply.) a. Intensity of the pressure b. Duration of the pressure c. Tissue's ability to tolerate the pressure d. Person's age e. Person's nutritional status

a. Intensity of the pressure b. Duration of the pressure c. Tissue's ability to tolerate the pressure d. Person's age e. Person's nutritional status The primary cause of pressure ulcers is, as the name suggests, pressure. However, it is more than just pressure; it is the intensity of the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue's ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.

When the nurse is performing a focused wound assessment on a patient, what information should be included in the documentation? (Select all that apply.) a. Location and size b. Characteristics of the wound bed c. Patient's response to wound treatment d. Patient's pain level e. Presence of drainage

a. Location and size b. Characteristics of the wound bed c. Patient's response to wound treatment e. Presence of drainage A focused wound assessment includes an evaluation of the wound's location, size, and color; presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient's response to the wound or wound treatment. The patient's pain level would be documented with his/her pain assessment.

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions will the nurse perform? (Select all that apply.) a. Measure the amount of drainage in the device prior to emptying. b. Label each drain and record them separately. c. Recompress the device after emptying. d. Secure the device to the patient's gown above the level of the wound. e. Check for kinks in the tubing.

a. Measure the amount of drainage in the device prior to emptying. b. Label each drain and record them separately. c. Recompress the device after emptying. e. Check for kinks in the tubing. Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement of the drainage. After emptying, recompress the device to maintain suction. Secure the container(s) to the patient's hospital gown below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label them and document observations by the drain label.

The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral pressure injury. Which is the most appropriate activity for the RN to delegate to the LPN? a. Place the client in a side-lying position. b. Initiate wound care protocol for standardized ulcer care. c. Meet with the wound specialist to identify measures to improve healing. d. Determine which treatments would best meet the healing needs of the client.

a. Place the client in a side-lying position. The best task for the LPN is to place the client in the side-lying position. Proper positioning requires nursing skills and is within the LPN's abilities and scope of practice. Initiating a wound care protocol, meeting with the wound specialist to identify measures to improve healing, and determining which treatments would best meet the healing needs of the client are outside the LPN's scope of practice, even though the LPN may assist the RN in determining the plan of care. These activities are the RN's responsibilities.

The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply. a. Reposition every 2 hours. b. Use a bed cradle as indicated. c. Apply protective pads to heels and elbows. d. Add a small amount of alcohol to the daily bath water. e. Provide perineal care every 8 hours and after incontinence.

a. Reposition every 2 hours. b. Use a bed cradle as indicated. c. Apply protective pads to heels and elbows. e. Provide perineal care every 8 hours and after incontinence. Unconscious clients are completely immobile, having lost the protective reflexes to shift body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours. Use of a bed cradle can protect the client's toes from breakdown due to weight from linens. Protective pads can be applied to the heels and elbows to reduce friction and shear. Appropriate perineal care is essential to keep waste products from excoriating the skin. The nurse can reduce skin dryness and irritation by adding a superfatty solution (i.e., baby oil or castile soap) to the daily bath water. Drying agents such as alcohol are avoided because dry skin can crack and break down.

A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene? a. The nurse asks the UAP to assess the wound. b. The nurse asks the UAP to report increased wound drainage. c. The nurse asks the UAP to observe changes in dietary intake. d. The nurse asks the UAP to change the dressing.

a. The nurse asks the UAP to assess the wound. Assessment and evaluation of a patient's skin and wounds, and the effectiveness of the treatment plan, are a nurse's responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education? a. "The wound will be red." b. "The wound will have pus." c. "The wound will be warm." d. "The wound will need to be treated

b. "The wound will have pus." An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105/g of tissue sampled when cultured. The wound will need to be treated for the infection.

The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about the prevention of pressure injuries while the client has limited mobility. Which statement by the client indicates the need for further teaching? a. "I will inspect my skin daily." b. "I can sit in my favorite chair all day." c. "I need to drink at least 2 liters of fluid daily." d. "I will make sure that my skin is clean and well moisturized."

b. "I can sit in my favorite chair all day." Sitting in one position all day can be a risk factor for pressure injury development. Options 1, 3, and 4 are preventative measures for pressure injury development.

When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include? a. A pressure ulcer that involves exposure of bone and connective tissue. b. A pressure ulcer that does not extend through the fascia. c. A pressure ulcer that does not include tunneling. d. A partial-thick wound that involves the epidermis.

b. A pressure ulcer that does not extend through the fascia. Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage 2 pressure ulcers are partial-thickness wounds that involve the epidermis and/or dermis.

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client? a. Pillow b. Foam pad c. Folded blankets d. Plastic-lined absorbent pad

b. Foam pad The client who cannot shift weight unassisted would have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for this purpose are those that have a tendency to equalize the client's weight on the pad. These include foam, water, gel, and alternating air products. A pillow provides cushion but does not distribute weight equally. A plastic-lined pad and folded blankets provide no pressure relief.

. The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"? a. Monitor temperature every 4 hours. b. Leave the dressing intact for 3 to 5 days. c. Apply an ice pack to the site to decrease edema formation. d. Maintain the right lower extremity in a dependent position.

b. Leave the dressing intact for 3 to 5 days. After surgery, graft sites are immobilized with a bulky cotton pressure dressing for 3 to 5 days to allow vascularization, or "take," of the newly grafted skin. Dressings would not be disturbed. Elevation and complete rest of the grafted area is required to allow blood vessels to connect the graft with the wound bed. Any activity that might cause movement of the dressing against the body and separation of the graft from the wound is prohibited, such as application of an ice pack. Additionally, cold promotes vasoconstriction.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? a. Milk b. Oranges c. Bananas d. Chicken

b. Oranges Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are 2 food groups that are high in the B vitamins.

. The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. Hard reddened skin b. Serous drainage c. Purulent drainage d. Warm, tender skin

b. Serous drainage Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

The nurse is caring for a client with a diabetic ulcer. What discharge instructions would the nurse provide to the client? Select all that apply. a. Wash feet with hot water daily. b. Use a mild soap when washing the feet. c. Use lanolin on the feet to prevent dryness. d. Wear open-toed shoes to allow air flow to the feet. e. Exercise the feet daily by walking and flexing at the ankle.

b. Use a mild soap when washing the feet. c. Use lanolin on the feet to prevent dryness. e. Exercise the feet daily by walking and flexing at the ankle. The client with a diabetic ulcer needs to take strict precautions and implement very specific measures to allow for wound healing. Interventions include washing the feet with warm (not hot) water daily with a mild soap, using lanolin to prevent drying and cracking, wearing closed-toed shoes that are well fitting while avoiding high-heeled and open-toed shoes, and exercising the feet daily by walking and flexing at the ankle to promote circulation.

The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity? a. Wound will be completely healed in 72 hours. b. Wound will show signs of healing within 2 weeks. c. Patient will develop no new pressure ulcers. d. Patient will ambulate twice a day.

b. Wound will show signs of healing within 2 weeks. A stage 3 pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and ambulating twice a day is more of an intervention.

The nurse understands which rationale to be appropriate for drying a wound after irrigation? a. Ensure the new dressing adheres to the wound. b. Ensure the new dressing remains occlusive. c. Prevent skin breakdown from moisture. d. Prevent infection from irrigate solution.

c. Prevent skin breakdown from moisture. Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being removed and reduces trauma to the wound. The type of dressing will determine how it lays in the wound and whether it is occlusive. The drying does not prevent infection.

. The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse should place the head of the bed in which position? a. Flat b. 90 degrees c. 30 degrees d. 45 degrees

c. 30 degrees When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? a. Notify the surgeon. b. Clamp the surgical drain. c. Change the dressing as prescribed. d. Remove and replace the perineal packing

c. Change the dressing as prescribed. Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse needs to change the dressing as prescribed. A surgical drain would not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time because this is expected. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse would not remove the perineal packing.

The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility? a. Patient will remain free of wound infections during the hospitalization. b. Patient will report pain management strategies and reduce pain to a tolerable level. c. Patient will be able to assist with position changes using over bed trapeze within 1 week. d. Patient will consume adequate nutrition to meet nutritional requirements within 1 week.

c. Patient will be able to assist with position changes using over bed trapeze within 1 week. Patient will be able to assist with position changes using over bed trapeze within 1 week is an appropriate goal for impaired mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for impaired tissue integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for acute pain. The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Impaired nutritional status.

When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out? a. The drain must be compressed after emptying to work properly. b. The drain must be connected to suction if ordered. c. The drain is not sutured in place so care is taken to not dislodge it. d. The suction pulls drainage away from the wound as it re-expands.

c. The drain is not sutured in place so care is taken to not dislodge it. The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction. Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a "popping sensation" and a wetness in the dressing, the nurse immediately suspects which complication? a. A wound infection b. The stitches came loose c. Wound dehiscence d. Wound crepitus

c. Wound dehiscence Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? a. A pink edematous hand b. Fiery red skin with edema in the nail beds c. Black fingertips surrounded by an erythematous rash d. A white color to the skin, which is insensitive to touch

d. A white color to the skin, which is insensitive to touch Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.

The nurse identifies which type of wounds heal by tertiary intention? a. An acute wound in which the patient has sutures placed when it happened. b. A pressure ulcer that was treated with dressing changes and is healed. c. An acute wound in which surgical glue was used to close the wound. d. A wound that was left open initially and closed later with sutures.

d. A wound that was left open initially and closed later with sutures. When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.

The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound? a. A wound with a large amount of drainage b. A wound that is tunneling c. A postsurgical incision with staples d. A wound with a moderate amount of drainage

d. A wound with a moderate amount of drainage Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a wound that is tunneling may require packing.

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What would the nurse do next? a. Irrigate the wound, and apply a dry sterile dressing. b. Leave the incision exposed to the air to dry the area. c. Apply a sterile dressing soaked with povidone-iodine. d. Apply a sterile dressing soaked with normal saline.

d. Apply a sterile dressing soaked with normal saline. Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the exposure of underlying tissues. These usually occur 6 to 8 days after surgery. The client needs to be instructed to remain quiet and avoid coughing or straining. The client needs to be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline would be used to cover the wound. The primary health care provider must be notified after applying this initial dressing to the wound.

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do? a. Cover the wound with a sterile gauze pad. b. Cover the wound with a transparent dressing. c. Put pressure on the wound with a sterile gauze pad. d. Cover the wound with gauze soaked with normal saline.

d. Cover the wound with gauze soaked with normal saline.

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? a. Purpura b. Petechiae c. Erythema d. Ecchymosis

d. Ecchymosis Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.

The nurse recognizes which intervention is not a form of mechanical debridement? a. Wet to dry dressings b. Whirlpool baths c. Wet to damp dressing d. Enzymatic dressing

d. Enzymatic dressing Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? a. Heels b. Sacrum c. Back of the head d. Greater trochanter

d. Greater trochanter The greater trochanter is at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position. When the client is lying supine, the heels, sacrum, and back of the head all are at risk, as are the elbows and scapulae.

The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse? a. Cleans the wound with a sterile normal saline solution b. Wraps and tapes a gauze dressing in place over the ulcer c. Applies the enzymatic agent to the area of necrosis d. Leaves the ulcer open to the air after the enzymatic agent is applied

d. Leaves the ulcer open to the air after the enzymatic agent is applied The wound needs to be cleansed with a sterile solution, such as normal saline, before applying the enzymatic agent. The nurse then applies a thin film of the enzymatic agent on the necrotic areas only and applies a loose, thin dressing taped securely in place.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? a. Intact skin b. Full-thickness skin loss c. Exposed bone, tendon, or muscle d. Partial-thickness skin loss of the dermis

d. Partial-thickness skin loss of the dermis In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? a. Foam b. Alginate dressing c. Hydrocolloid dressing d. Semipermeable transparent film

d. Semipermeable transparent film The client's wound has moderate drainage. Recall that foam, alginate, and hydrocolloid dressings are applied to wounds with moderate to heavy drainage. Semipermeable transparent films are applied to dry wounds.

The nurse identifies which syringe to use when irrigating a patient's deep wound? a. 5-mL syringe b. 10-mL syringe c. 3-mL syringe d.30-mL syringe

d.30-mL syringe A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi.