chapter 30 craven questions

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 I -Stage II -Stage III -Stage IV

-Stage II

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 - stage I pressure injury - stage III pressure injury -stage IV pressure injury

-stage II pressure injury

What are the two major processes involved in the inflammatory phase of wound healing? -Bleeding is stimulated and epithelial cells are deposited. -Granulation tissue is formed and collagen is deposited. -Collagen is remodeled and an avascular scar forms. -Blood clotting is initiated and WBCs move into the wound.

blood clotting is initiated and WBC move into the wound

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. -secondary intention. -tertiary intention. -dehiscence.

primary intention

A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing of a highly absorbent nature. Which type of dressing should the nurse use for this client? - gauze - transparent -hydrocolloid - bandage

gauze

A client who was injured when he stepped on a rusted nail visits the health care facility. How should the nurse describe this wound? -Abrasion -Avulsion - Ulceration - Puncture

puncture

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply. - Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. - Change the dressing midway between meals. - Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. - Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. -Apply an absorbent dressing material as the first layer of the dressing. - Apply a nonabsorbent material over the first layer of absorbent material.

-Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. - Change the dressing midway between meals. - Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound.

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What would alert the nurse to the possibility that the client's circulation is impaired? Select all that apply. -Fingers with quick capillary refill -Pale, cool hand - Decreased radial pulse -Absence of cyanosis - Reports of finger numbness

-Pale, cool hand -Decreased radial pulse -Reports of finger numbness

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? - antihypertensive drugs -potassium supplements - laxatives -corticosteroids

-corticosteroids

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 gauze dressing precut halfway to fit around the IV line - a dressing with a nonadherent coating -a gauze dressing premedicated with antibiotics -a transparent film

a transparent film

The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? -an alginate dressing - transparent film - a hydrogel dressing - an antimicrobial dressing

an alginate dressing

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? -Size -Depth -Tunneling -Direction

depth

A home care nurse is visiting an older adult client. During the visit, the client's spouse sustains a minor thermal injury when cooking. The nurse intervenes, doing which of the following first? -Refrain from removing any of the client's jewelry. -Flush the area with copious amounts of cool water. -Pull off any clothes sticking to the burned area. -Apply any antimicrobial ointment available at home.

flush the area with copious amounts of cool water

A health care provider orders a dressing to cover a newly developed partial-thickness wound with minimal drainage. What would be the best type of dressing for this wound? - saline-moistened dressing - dressing secured with Montgomery straps -hydrocolloid dressing -foam dressing

hydrocolloid dressing

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. -elevate the head of the bed 90 degrees four times daily -provide incontinent care every 2 hours and as needed -pull the client up in bed as needed -turn the client every 2 hours when the client is in bed -encourage the client to take fluids every 2 hours

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

A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? -primary intention - secondary intention -tertiary intention -desiccation

secondary intention

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 I - Stage II -Stage III -Stage IV

stage II

A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound? -suspected deep tissue injury -stage II wound -stage III pressure injury -unstageable wound

stage III pressure injury

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 - pressure ulcer -burn -deep laceration

surgical incision

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? -"This is normal tissue." -"That is old clotted blood underneath the wound" - "That is called undermining, a type of tissue erosion." -"That is necrotic tissue, which must be removed to promote healing."

that is necrotic tissue which must be removed to promote healing

When the nurse is caring for a client with an open wound, which characteristic should be observed if the wound heals by primary intention? -Granulation tissue needs additional time to extend across the wound. -The wound edges have to be brought together with closure material. -The wound edges are directly next to each other. -Drainage devices have to be used to promote quick healing.

the wound edges are directly next to each other

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 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. -The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. The wound is 3 × 5 cm, with yellow tissue covering the entire wound. -The wound is a 3 × 5-cm blood-filled blister.

the wound is 3 X 5 cm, with yellow tissue covering the entire wound

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. -True -False

true

Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues. -True -False

true

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? -elevate the head of the bed 90 degrees -use pillows to maintain a side-lying position as needed - provide incontinent care every 4 hours as needed -place a foot board on the bed

use pillows to maintain a side lying position as needed

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply. -"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." -"Most pressure injuries occur over the trochanter and calcaneus." -"Generally, a pressure injury will not appear within the first 2 days in a person who has not moved for an extended period of time." -"The major predisposing factor for a pressure injury is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues." -"The skin can tolerate considerable pressure without cell death, but for short periods only." -"The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."

-"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." -"The skin can tolerate considerable pressure without cell death, but for short periods only." -"The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."

A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing of a highly absorbent nature. Which type of dressing should the nurse use for this client? -transparent - hydrocolloid -gauze - bandage

-gauze

The client has an infected nonhealing wound to which negative-pressure wound therapy (NPWT) has been applied. What actions would the nurse employ for this client? Select all that apply. -measure and record the amount of drainage each shift -empty or replace the canister on the machine when full or nearly full -assess for a problem if the machine alarms -disconnect the machine for 2 hours daily to allow the client to bathe and ambulate - change the wound dressing every day

-measure and record the amount of drainage each shift -empty or replace the canister on the machine when full or nearly full -assess for a problem if the machine alarms

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 -keep the ice pack applied to the skin for at least 1 hour

-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

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? - 2 × 2 in (5 × 5 cm) gauze - hydrocolloid dressing -transparent film -hydrogel sheet

-transparent film

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 Penrose drain is a closed drainage system that is connected to an electronic suction device. - A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. -A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

a penrose drain promotes passive drainage into a dressing

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 clean separation of skin and tissue with a smooth, even edge -a separation of skin and tissue in which the edges are torn and irregular -a wound in which the surface layers of skin are scraped away - a shallow crater in which skin or mucous membrane is missing

a separation of skin and tissues in which the edges are torn and irregular

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? -a small plastic ruler - a sterile tongue blade lubricated with water soluble gel -an otic curette -a sterile, flexible applicator moistened with saline

a sterile flexible applicator moistened with saline

Which is not considered a skin appendage? -Hair - Connective tissue -Sebaceous gland -Eccrine sweat glands

connective tissue

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? -incision -avulsion -contusion -puncture

contusion

Which action should the nurse perform when applying negative pressure wound therapy? -Cut foam to the shape of the wound and place it in the wound. -increase the negative pressure setting until drainage is brisk. - Irrigate the wound thoroughly using normal saline and clean technique. -Test the seal of the completed dressing by briefly attaching it to wall suction.

cut foam to the shape of the wound and place it in the wound

A nurse applies an aquathermia pad on the back of a client with arthritis. What is the expected action that will occur with this application of heat? -decreased blood flow to the area - dilated peripheral blood vessels - increased venous congestion -decreased inflammatory response

dilated peripheral blood vessells

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? -fistula -dehiscence -hemorrhage -evisceration

evisceration

Dehiscence is the softening of tissue due to excessive moisture. -True -False

false

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? -circular turn only -spiral turn - figure-of-eight turn - recurrent bandaging

figure of eight turn

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? -"I should keep this on my ankle until it is numb." - "I must wait 15 minutes between applications of cold therapy." - "I will put a layer of cloth between my skin and the ice pack." -"I can let this stay on my ankle an hour at a time."

i will put a layer of cloth between my skin and the ice pack

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? -"You will receive medication through this device." - "This drain minimizes the chance for bacteria to enter the surgical site." - "It provides a way to remove drainage and blood from the surgical wound." - "The bulb-like system will stay in place permanently after your mastectomy."

it provides a way to remove drainage and blood from the surgical wound

A physician uses sutures during the surgery on a client at a health care facility. What are sutures? -a bridge that holds two wound margins together - a strip or roll of cloth wrapped around a body part -knotted ties that hold an incision together - tubes that provide a pathway for drainage

knotted ties that hold an incision together

The nurse would recognize which of these devices as an open drainage system? -Jackson-Pratt drain -Hemovac -Penrose drain -Negative pressure dressing

penrose drain

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? -Glascow scale - Braden scale -FLACC scale -Morse scale

braden scale

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 -reinserting the protruding structures and applying a pressure dressing -placing the client in the low Fowler position -using sterile technique - packing the wound with iodoform gauze

-covering the wound with a gauze moistened with normal saline - placing the client in the low Fowler position - using sterile technique

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply. -"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." - "Most pressure injuries occur over the trochanter and calcaneus." - "Generally, a pressure injury will not appear within the first 2 days in a person who has not moved for an extended period of time." - "The major predisposing factor for a pressure injury is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues." -"The skin can tolerate considerable pressure without cell death, but for short periods only." -"The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."

"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation.

The wound care nurse is performing skin assessments for clients at risk for the development of skin alterations. Which clients does the nurse identify as at greatest risk for skin alterations? Select all that apply. -A client with morbid obesity -A client with reports of excessive perspiration -A client with cataracts -A client with hypertension - A client that has a low BMI

-A client with morbid obesity -A client with reports of excessive perspiration -A client that has a low BMI

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? -The nurse uses wet-to-dry dressings continuously. -The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. -The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. - The nurse packs the wound cavity tightly with dressing material.

-The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure injury? Select all that apply. -Clean the wound with each dressing change using aggressive motions to remove necrotic tissue. -Use povidone-iodine or hydrogen peroxide to irrigate and clean the injury. -Use whirlpool treatments, if prescribed, until the ulcer is considered clean. -Keep the injury tissue moist and the surrounding skin dry. - Use a dressing that absorbs exudate but maintains a moist healing environment. -Pack wound cavities densely with dressing material to promote tissue healing.

-Use whirlpool treatments, if prescribed, until the ulcer is considered clean. -Keep the injury tissue moist and the surrounding skin dry. -Use a dressing that absorbs exudate but maintains a moist healing environment.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? -a large wound with considerable tissue loss allowed to heal naturally - a wound left open for several days to allow edema to subside -a wound healing naturally that becomes infected. -a surgical incision with sutured approximated edges

-a surgical incision with sutured approximated edges

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. -an older adult who is confined to bed - a client with a peripheral vascular disorder -a client who is obese -a client who eats a diet high in vitamins A and C -a client who is taking corticosteroid drugs -a 10-year-old client with a surgical incision

-an older adult who is confined to bed -a client with a peripheral vascular disorder -a client who is obese -a client who is taking corticosteroid drugs

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 I pressure injury -stage II pressure injury -stage III pressure injury -stage IV pressure injury

-stage III pressure injury

The health care provider has ordered a cold ice bag to be applied to the wrist of a client with a sprain. The nurse will ensure that the cold application is at what temperature before application? -26.6°-33.8° C (80°-93° F) - 18.3°-26.6° C (65°-80° F) -10°-18.3° C (50°-65° F) -Below 10° C (below 50° F)

10°-18.3° C (50°-65° F)

A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected? -skin pallor -blister formation -full-thickness skin loss -eschar formation

full thickness skin loss

A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe the client's wound? -a clean separation of skin and tissue with smooth, even edges -a shallow crater in which skin or mucous membrane is missing -a wound in which the surface layers of the skin are scraped away - a separation of skin and tissue in which the edges are torn and irregular

a clean separation of skin and tissue with smooth even edges

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? - a client who lifts himself up on his elbows -a client who lies on wrinkled sheets -a client who must remain on his back for long periods of time -a client sitting in a chair who slides down

a client sitting in a chair who slides down

The nurse should use extreme caution when applying heat therapy to which of the following clients? -a client who is receiving corticosteroids - a client with a venous ulcer - a client with high pain sensitivity -a client who is unconscious

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: -an abrasion. -a laceration. - a contusion. -a puncture.

a laceration

Which statement accurately describes a developmental consideration when assessing skin integrity of clients? -In children younger than 2 years, the skin is thicker and stronger than it is in adults. -An infant's skin and mucous membranes are injured easily and are subject to infection. - A child's skin becomes increasingly at risk for injury and infection. -In the older adult, circulation and collagen formation are increased.

an infants skin and mucous membranes are injured easily and are subject to infection

The nurse would recognize which client as being particularly susceptible to impaired wound healing? -a client whose breast reconstruction surgery required numerous incisions -an obese woman with a history of type 1 diabetes -a man with a sedentary lifestyle and a long history of cigarette smoking -A client who is NPO (nothing by mouth) following bowel surgery

an obese woman with a history of type 1 diabetes

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? -administering pain medications on a p.r.n. and regular basis -assisting the client in moving to prevent strain on the suture line -telling the client that a mild fever is a normal response -preventing scar formation so it does not limit joint movement

assisting the client in moving to prevent strain on the suture line

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? -puncture - laceration - contusion - avulsion

avulsion

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? -Use clean technique to clean the wound. -Clean the wound in a circular pattern, beginning on the perimeter of the wound. - Clean the wound from the top to the bottom and from the center to outside. - Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

clean the wound from the top to the bottom and from the center to outside

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and: -closing the wound area with reinforced adhesive skin closures. -pouring sterile hydrogen peroxide into the abdominal cavity and packing it with gauze. - covering the wound area with sterile towels moistened with sterile 0.9% saline. - holding the wound together until the health care provider arrives.

covering the wound area with sterile towels moistened with sterile 0.9% saline

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? -exerting equal, but not excessive, tension with each turn of the bandage -wrapping distally to proximally -elevating and supporting the stump -keeping the bandage free of gaps between turn

elevating and supporting the stump

As a part of the senior citizen health program, the community health nurse arranges a free skin screening for the older adults. Which of the following would the nurse find when assessing the skin of older adult clients? -Milia -Lanugo -Acne vulgaris - Liver spots

liver spots

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? -The heart must be able to pump adequately. -The volume of circulating blood must be sufficient. -Arteries and veins must be patent and functioning well. -Local capillary pressure must be lower than external pressure.

local capillary pressure must be lower than external pressure

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? -autolytic debridement -biosurgical debridement -enzymatic debridement -mechanical debridement

mechanical debridement

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? -"This is normal tissue." - "That is called slough, and it will usually fall off." - "You are seeing undermining, a type of tissue erosion." - "Necrotic tissue is devitalized tissue that must be removed to promote healing."

necrotic tissue is devitalized tissue that must be removed to promote healing

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? -document the assessments and intervention - reinforce the dressing with additional layers - administer pain medications intramuscularly - notify the physician and prepare for surgery

notify the physician and prepare for surgery

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? -document the assessments and intervention - reinforce the dressing with additional layers - administer pain medications intramuscularly - notify the physician and prepare for surgery

notify the physician and prepare for surgery

A nurse is caring for a client with a puncture wound in the proliferation phase of the wound repair process. Which description reflects this phase of the wound repair process? -physiologic defense immediately after tissue injury -period during which new cells fill and seal a wound -process by which damaged cells recover and reestablish normal function -period during which the wound undergoes change and maturation

period during which new cells fill and seal a wound

A client at a health care facility who underwent an appendectomy says to the nurse that he feels like something has "given way." On inspecting the surgical wound, the nurse notes pinkish drainage on the dressing. What intervention should the nurse perform in this case? - placing sterile dressings moistened with normal saline over the area - informing the head nurse immediately about the client's condition -positioning the client to put the least strain on the operated area - inspecting the wound to determine the extent of the secretion

position the client to put the least strain on the operated area

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? -hemostasis -inflammatory phase - maturation phase -proliferation phase

proliferation phase

What are functions of the skin? Select all that apply. -Protection - Temperature regulation - Sensation -Vitamin C production - Immunologic

protection temp regulation sensation immunologic

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? -"I may have staples in place for a number of days." -"I will not remove the staples myself." -"After delivery, I will have sutures in place." -"Reinforced adhesive skin closures will hold my wound together until it heals."

reinforced adhesive skin closures will hold my wound together until it heals

A nurse is assisting a physician who is using the sharp debridement technique at the bedside of a client at a health care facility. What is the purpose of sharp debridement? -removes necrotic tissue from healthy area of a wound -breaks down and liquefies wound debris - allows the body's enzymes to soften and liquefy tissue -physically removes exudate from a deep wound

removes necrotic tissue from healthy are of a wound

Which best describes the proliferative phase, the third phase of the wound healing process? -the onset of vasoconstriction, platelet aggregation, and clot formation - marked by vasodilation and phagocytosis as the body works to clean the wound - reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization - decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound

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

Which best describes the proliferative phase, the third phase of the wound healing process? -the onset of vasoconstriction, platelet aggregation, and clot formation -marked by vasodilation and phagocytosis as the body works to clean the wound -reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization - decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound

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

A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? -primary intention - secondary intention - tertiary intention - desiccation

secondary intention

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? -primary intention -maturation -secondary intention - tertiary intention

secondary intention

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as: -serous. -sanguineous. -serosanguineous. -purulent.

serosanguineous

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? -serous - purulent - serosanguineous - sanguineous

serosanguineous

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? -serous -purulent - serosanguineous - sanguineous

serosanguineous

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document? -serous -sanguineous -serosanguineous -purulent

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? -friction -necrosis of tissue - ischemia -shearing force

shearing force

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? -friction -necrosis of tissue -ischemia -shearing force

shearing force

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and unblanchable. How will the nurse categorize this pressure injury? -stage I -stage II -stage III -stage IV

stage 1

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 I -stage II -stage III -stage IV

stage 3

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 I - stage II -stage III -stage IV

stage IV

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 I -stage II -stage III -stage IV

stage IV

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? -Epidermis - Dermis -Subcutaneous tissue - Muscle layer

subcutaneous tissue

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? - The nurse uses friction when cleaning the wound to loosen dead cells. -The nurse swabs the wound with povidone-iodine to fight infection in the wound. -The nurse works outward from the wound in lines parallel to it. -The nurse swabs the wound from the bottom to the top.

the nurse works outward from the wound in lines parallel to it

A client has undergone an open surgical procedure. Which teaching provided by the nurse accurately reflects what the client should expect during the remodeling period? -"Blood vessels will constrict to control blood loss." -"Neutrophils and monocytes will migrate to the site of your incision." - "Granulation tissue will start to form." -"The wound will contract and scarring will shrink."

the wound will contract and scarring will shrink

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 wraps help approximate wound edges. -They facilitate closure of acute wounds. -The wraps help prevent abscess formation.

they provide light support to the area

A client is confined to bed due to a spinal cord injury. The client's plan of care identifies a nursing diagnosis of Risk for Impaired Skin Integrity related to immobility. What would be most appropriate for the nurse to do when providing skin care to this client? -Avoid applications of lotions or creams to the client's skin., -Apply alcohol-based solutions to skin areas, especially creases. - Limit complete bathing to twice a week. -Use light dusting of powder in skin folds.

use light dusting of powder in skin folds

A client is confined to bed due to a spinal cord injury. The client's plan of care identifies a nursing diagnosis of Risk for Impaired Skin Integrity related to immobility. What would be most appropriate for the nurse to do when providing skin care to this client? -Avoid applications of lotions or creams to the client's skin., -Apply alcohol-based solutions to skin areas, especially creases. -Limit complete bathing to twice a week. - Use light dusting of powder in skin folds.

use light dusting of powder in skin folds

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? -Superficial, which may be pinkish or red with no blistering - May vary from brown or black to cherry red or pearly white; bullae may be present -Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown -A superficial partial-thickness burn, which can appear dry and leathery

usually moist with blisters, which may be pink, pale, red, pale ivory, or light yellow-brown

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. - "Very little scar tissue will form." - "This is a simple reparative process." - "The margins of your wound are widely separated." -"Your wound will be purposely left open for a time." -"Your wound edges are right next to each other."

very little scare tissue will form this is a simple reparative process the margins of your wound are widely separated