Chapter 32: Skin Integrity and Wound Care - PrepU

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"

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 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

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

Assess the client's wounds and vital signs

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?

Braden Scale

Which is not considered a skin appendage?

Connective tissue

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

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order.

Hemostasis Inflammatory Proliferation Maturation

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

Insert a swab into the wound Press and rotate the swab several times over the wound surfaces Place the swab in the culture tube when done

When applying an external heating pad, which prescription from the health care provider would the nurse question?

Leave heating pad on for 45 minutes

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

Color Classification of Open Wounds

R = red—protect Y = yellow—cleanse B = black—debride Mixed wound—contains components of RY&B wounds

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure?

Red

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

Stop removing the staples and inform the surgeon

A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product?

The dressing allows oxygen exchange between the wound and environment

A client who has 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

Glasgow scale

This is an assessment tool used to determine consciousness in clients. The Score of 15 reveals a fully oriented person. 3 is deep coma., Used for head trauma- Score 3-15, based on Eye opening, Verbal response and Motor response.

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

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury?

a critical care client

Penrose drain

a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing

Alginates

absorb exudate, debride, 1-3 days

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 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 is taking corticosteroid drugs

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

Unstageable

base of ulcer covered by slough and/or eschar in wound bed

Sanguineous wound drainage

bloody drainage

Serous wound drainage

clear and watery

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?

contusion

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

dehiscence

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?

elevating and supporting the stump

Stage IV

full-thickness skin loss with extensive destruction

Stage III

full-thickness skin loss; not involving underlying fascia

Jackson-Pratt drain

hollow bulb-like device used to collect drainage

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 nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has prescribed fly larvae to debride the wound. Which type of debridement does the nurse understand has been prescribed?

mechanical debridement

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

milia

Hydrogels

moist, minimal absorption, reduce pain

Stage I

nonblanchable erythema of intact skin

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 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

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

serosanguineous

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

Purulent wound drainage

thick, yellow, green, tan, or brown

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

transparent

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

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 evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?

Albumin 2.8 mg/dL (28.0 g/L)

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity?

Clean perineal area daily but do not bathe full body on a daily basis

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

A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse?

Discard the swab, clean the wound with a non-antimicrobial cleanser, and obtain another swab

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 with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply.

Draw the shape of the wound with a description Measure the wound's length and width Assess color, drainage, presence of pain, or complications

Morse scale

Fall risk assessment

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 has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

Fingers with quick capillary refill No finger numbness or tingling Warm hand

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

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 the inside of the culture tube sterile prior to collecting the culture

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client?

Monitor intake and output

Open or closed wound

Open - skin surface is broken Closed - skin surface is not broke

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

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 adheres to the wound bed. Which modification is most appropriate?

Reduce the time interval between dressing changes

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

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 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?

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 works outward from the wound in lines parallel to it

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

To splint the area when engaging in activity

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 sterile, flexible applicator moistened with saline

The nurse is assessing the wounds of clients in a burn unit. Which would most likely heal by primary intention?

a surgical incision with sutured approximated edges

Flacc scale

face, legs, activity, cry, consolability

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

Stage II

partial thickness skin loss

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 limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have?

Tetanus, infection, wound care, and pain control