Chapter 32 PrepU

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

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

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 sitting in a chair who slides down

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

dehiscence

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

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 client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

assess the client's wound and vital signs

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

True

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 is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

discontinue the therapy and assess the client

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?

hemostasis phase

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

keep the swab and inside of culture tube sterile

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

rotate the swab several times over the wound surface to obtain an adequate specimen

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:

second degree or partial thickness

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion?

tearing of a structure from its normal position

Which is not considered a skin appendage?

Connective tissue

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

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

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

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

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