Chapter 31/32 Hygiene, Integrity, Skin/Wound care

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

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

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?"

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

"Very little scar tissue will form."

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

Dry the cleaned areas and apply emollient as indicated

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

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals?

She has motivation to participate in self-care.

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 II

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

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate?

Store the hearing aid in a cool environment

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is most appropriate?

Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath.

T/F A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

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

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

adolescents

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 nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?

back massage

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

fish

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps?

how often the client brushes and flosses teeth

When the nurse cleanses the client's leg during a bed bath, it will allow for:

increased circulation

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

very little scar tissue will form

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse?

"I use cotton-tipped applicators daily to remove cerumen."

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response?

"I will set up your bath for you, and you can use the call button to let me know if you need help."

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

"I will use conditioner so that the lice eggs will slide off my hair."

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?

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

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

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."

A client reports developing repeated furuncles in the groin area. What statement(s) made by the client indicates to the nurse that education about prevention will be required? Select all that apply.

- "I ruptured the furuncle so that hydrogen peroxide and an antibiotic cream can be applied." - "I have aspirated the drainage with a needle to relieve the pressure and the pain."

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply.

- "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." - "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." - "Hygiene measures have no effect on skin."

Which statements accurately describe findings the nurse would document when performing a physical assessment of the oral cavity? Select all that apply.

- Caries may exist in the teeth, resulting from the failure to remove plaque. - Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. - Cheilosis may present as reddened fissures at the angles of the mouth.

Which action(s) does the nurse take to care for a client unable to care for dentures? Select all that apply.

- Clean the dentures with a mild commercial cleaning agent - Clean dentures with a soft toothbrush - Store dentures in water in a covered container - Keep dentures in a denture cup while carrying them to the sink - Remove upper dentures by rocking them forward

The nurse is preparing to irrigate a client's abdominal wound following wound dehiscence. Arrange the presented nursing activities in the correct order. Use all options.

1. Discuss the procedure with the client and assess client knowledge. 2. Gather equipment required for a dressing change. 3. Drape the client to expose the area of the wound. 4. Position the client to facilitate filling the wound cavity with solution 5. Open and prepare supplies following the principles of surgical asepsis. 6. Don gloves and other personal protective equipment. 7. Fill the syringe with solution, and instill it into the wound. 8. Dry the skin surrounding the wound.

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

A nurse caring for the skin of clients of different age groups should consider which accurately described condition?

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

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

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

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them?

Apply moist saline compresses to loosen crusts before attempting to remove the staples.

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.

The nurse is caring for an adult client that had a cerebrovascular accident (CVA) 1 month ago. How would the nurse assist the client in relearning self-care?

Assist the client in dressing oneself after offering alternative techniques

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

At stage 1 pressure injury

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal?

Normal saline

The nurse is caring for a client that is comatose. What action by the nurse will prevent complications related to the provision of oral care?

Use small amounts of water and an oral suction device.

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?

independent shower

A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of:

pediculosis

Which health problem is most clearly suggestive of a history of inadequate dental care?

periodontitis

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

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important to use in order to individualize care for this client?

suction toothbrush

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client?

the client should use an electric razor

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is:

to provide drainage for bile.

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?

traditional bed bath with linen change

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body?

underneath the breasts and in between skinfolds