Chapter 32: Skin Integrity and Wound Care

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. Utilize the culture swab to obtain cultures from multiple sites. Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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 packs the wound cavity tightly with dressing material. 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 selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? The nurse elevates the foot of the bed. The nurse uses a ring cushion to protect reddened areas from additional pressure. The nurse increases the amount of time the head of the bed is elevated. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. The nurse uses a ring cushion to protect reddened areas from additional pressure. The nurse elevates the foot of the bed. The nurse increases the amount of time the head of the bed is elevated.

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain? Staging the wound for assessment If there is contamination of dirt and debris The status of the client's tetanus immunization The event leading up to the trauma

The status of the client's tetanus immunization

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

dehiscence.

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." "Be sure to take at least two showers daily to remove all microorganisms from the skin." "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection."

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Do you experience incontinence?" "Have you had any recent illnesses?"

"Do you experience incontinence?"

The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? "Drainage will occur by gravity and capillary action." "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." "You will receive medication through this device."

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

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

"That is necrotic tissue, which must be removed to promote healing."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? "The margins of your wound are not in direct contact." "The surgeon will leave your wound open intentionally for a period of time." "Very little scar tissue will form." "This is a complex reparative process."

"Very little scar tissue will form."

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? In children younger than 2 years, the skin is thicker and stronger than in adults. An individual's skin changes little over the life span. An infant's skin and mucous membranes are easily injured and at risk for infection. A child's skin becomes less resistant to injury and infection as the child grows.

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

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Inform the client that this is an expected occurrence and not to worry. Allow the wound and intestinal contents to remain open to air. Pack the wound with gauze pads and a dry sterile dressing. Apply saline solution-moistened gauze over the protruding area.

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? Notify the health care provider of the pain. Assess the client's wound and vital signs. Administer the prescribed analgesic. Document the pain and vital signs.

Assess the client's wound 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? FLACC scale Glasgow scale Morse scale Braden scale

Braden scale

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. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Use clean technique to clean the wound. 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.

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

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? Infection of the wound Herniation of the wound Evisceration of the viscera Dehiscence of the wound

Dehiscence of the wound

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? Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

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

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 works outward from the wound in lines parallel to it. The nurse swabs the wound with povidone-iodine to fight infection in the wound. The nurse swabs the wound from the bottom to the top.

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 To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing

To splint the area when engaging in activity

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? Apply moist dressing Wound irrigation Debridement Gentle cleansing

Wound irrigation

nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? Wound irrigation Apply moist dressing Debridement Gentle cleansing

Wound irrigation

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 a client who must remain on the back for long periods of time a client who lifts himself up on the elbows a client who lies on wrinkled sheets

a client sitting in a chair who slides down

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 surgical incision with sutured approximated edges a wound healing naturally that becomes infected. a wound left open for several days to allow edema to subside

a surgical incision with sutured approximated edges

The nurse would recognize which client as being particularly susceptible to impaired wound healing? 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 whose breast reconstruction surgery required numerous incisions A client who is NPO (nothing by mouth) following bowel surgery

an obese woman with a history of type 1 diabetes

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 corticosteroids laxatives potassium supplements

corticosteroids

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 Evisceration Necrosis Maceration

desiccation

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? circular turn spica turn spiral-reverse turn figure-of-eight turn

figure-of-eight turn

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? Banana Fish Green beans Pasta salad

fish

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? maturation secondary intention primary intention tertiary intention

secondary intention

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 IV stage I stage II stage III

stage II

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury? stage III stage IV stage I stage II

stage III

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? adhesive strips with eyelets gauze transparent hydrocolloid

transparent

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? 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 elevate the head of the bed 90 degrees

use pillows to maintain a side-lying position as needed

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. Avoid using irrigation to clean the wound before changing the dressing. Apply dry gauze to the wound and carefully apply saline to saturate it. Exert firm pressure using forceps to pack the wound tightly with moistened dressing.

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

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? Cleanse the wound after obtaining the wound culture. Keep the swab and the inside of the culture tube sterile prior to collecting the culture. Stroke the culture swab on surrounding skin first. Utilize the culture swab to obtain cultures from multiple sites.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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 to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site? a gauze dressing precut halfway to fit around the IV line a gauze dressing premedicated with antibiotics a transparent film a dressing with a nonadherent coating

a transparent film

A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider? hydrocolloid transparent hydrogel alginate

alginate

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing concern should the nurse rank with the priority when formulating the client's care plan? altered tissue integrity acute pain knowledge deficiency altered body image

altered tissue integrity

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 evisceration hemorrhage dehiscence

evisceration

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? hemorrhage fistula dehiscence evisceration

evisceration

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 purulent drainage from the wound bed in order to accurately assess it removing dead or infected tissue to promote wound healing removing excess drainage and wet tissue to prevent maceration of surrounding skin stimulating the wound bed to promote the growth of granulation tissue

removing dead or infected tissue to promote wound healing

The client, after undergoing an appendectomy for a ruptured appendix, has an open drain left in the wound. The health care provider prescribes removal of 2 in (5 cm) of drain every day. Which action will the nurse take? document only this action and client response reposition the safety pin or clip on the drain weigh the soiled dressing to determine approximate drainage apply extra dressing to absorb continued drainage

reposition the safety pin or clip on the drain

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? Document the pain and vital signs. Notify the health care provider of the pain. Administer the prescribed analgesic. Assess the client's wound and vital signs.

Assess the client's wound and vital signs.

A client with anorexia nervosa has developed a pressure injury on the sacrum. Which laboratory result would indicate the client is at nutritional risk? Arm muscle circumference 90% of standard Albumin level of 3.5 mg/dL Body weight decrease of 3% Total lymphocyte count of 1,000/mm3

Total lymphocyte count of 1,000/mm3

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 II stage IV stage I stage III

s

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? purulent serosanguineous sanguineous serous

serosanguineous

A client's risk for the development of a pressure injury is most likely due to which lab result? sodium 135 mEq/L glucose 110 mg/dL hemoglobin A1C 7% albumin 2.5 mg/dL

albumin 2.5 mg/dL

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? laceration puncture avulsion contusion

avulsion

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? "Be sure to take at least two showers daily to remove all microorganisms from the skin." "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "How many meals a day do you eat?" "Have you had any recent illnesses?" "Do you use any lotions on your skin?" "Do you experience incontinence?"

"Do you experience incontinence?"

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? "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "As soon as the infection clears, your surgeon will staple the wound closed." "Your wound will heal slowly as granulation tissue forms and fills the wound."

"Your wound will heal slowly as granulation tissue forms and fills the wound."

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. Decreased radial pulse No finger numbness or tingling Fingers with quick capillary refill Cyanosis Warm hand

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

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 To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing

To splint the area when engaging in activity

Which client(s) is considered at risk for skin alterations? Select all that apply. an adolescent with multiple body piercings a client with diabetes a client receiving radiation therapy a client undergoing cardiac monitoring a client in a monogamous same-sex relationship

an adolescent with multiple body piercings a client with diabetes a client receiving radiation therapy

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? uses a figure-of-8 technique applies wrap from proximal to distal direction keeps bandage free of wrinkles used metal clips to secure end of bandage

applies wrap from proximal to distal direction

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 must wait 15 minutes between applications of cold therapy." "I can let this stay on my ankle an hour at a time." "I should keep this on my ankle until it is numb." "I will put a layer of cloth between my skin and the ice pack."

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

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles. Use an aquathermia pad during the treatment to create heat and circulate the water.

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? Apply a transparent dressing over the incision site. Apply a skin protectant to the incision site. Apply a sterile gauze sponge over the incision site. Apply a skin protectant to the skin around the incision.

Apply a skin protectant to the skin around the incision.

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? Herniation of the wound Evisceration of the viscera Infection of the wound Dehiscence of the wound

Dehiscence of the wound

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy. Which interventions should the nurse follow to apply the T-binder? (Select all that apply.) Place the precut drain sponge on the anus. Fasten the crossbar around the waist. Pin the tails to the belt of the T-binder. Clean the insertion in a circular manner. Pass the tails through the client's legs.

Fasten the crossbar around the waist. Pin the tails to the belt of the T-binder. Pass the tails through the client's legs.

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? Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain.

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

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 III Stage I Stage II Stage IV

Stage II

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? Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision. Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple is removed.

Stop removing staples and inform the surgeon

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 an otic curette a small plastic ruler a sterile tongue blade lubricated with water soluble gel

a sterile, flexible applicator moistened with saline

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

dehiscence

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? copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell foul-smelling drainage that is grayish in color small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color

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? sanguineous serosanguineous serous purulent

serosanguineous

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

use pillows to maintain a side-lying position as needed

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. reinserting the protruding structures and applying a pressure dressing 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 covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position

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

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

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 works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider."

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

A full-thickness or third-degree burn develops a leathery covering called a(an): eschar. static. abrasion. erythema.

eschar.

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? Necrosis Evisceration Maceration Desiccation

Desiccation

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? Superficial contusion accompanied by pruritus Diffuse dermatitis accompanied by pruritus Superficial abscess accompanied by pruritus Diffuse fungal infection accompanied by pruritus

Diffuse dermatitis accompanied by pruritus

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. Gently rub and massage the area to warm it up. Notify the health care provider of the findings. Document the findings in the client's medical record.

Discontinue the therapy and assess the client.

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 STAT Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

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 staples and apply an abdominal pad over the incision. Apply an occlusive pressure dressing after removing the staples. Apply adhesive wound closure strips after each staple is removed. Stop removing staples and inform the surgeon

Stop removing staples and inform the surgeon

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Pack the wound with gauze pads and a dry sterile dressing. Apply saline solution-moistened gauze over the protruding area. Allow the wound and intestinal contents to remain open to air. Inform the client that this is an expected occurrence and not to worry.

Apply saline solution-moistened gauze over the protruding area.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Do not attempt to remove the sutures because the wound needs more time to heal. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Carefully pick the crusts off the sutures with the forceps before removing them.

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force? improving the client's hydration pulling the client up from under the arms preventing the client from sliding in bed pulling the sheets to reposition the client every 2 hours

preventing the client from sliding in bed

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 is a closed drainage system that is connected to an electronic suction device. A Penrose drain promotes passive drainage into a dressing. 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.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Inform the client that this is an expected occurrence and not to worry. Apply saline solution-moistened gauze over the protruding area. Pack the wound with gauze pads and a dry sterile dressing. Allow the wound and intestinal contents to remain open to air.

Apply saline solution-moistened gauze over the protruding area.

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps? Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. Apply skin barrier only on the side of the wound without any irritation. Apply skin barrier only on the right side of the wound over the irritation. Apply skin barrier over the area of irritation to prevent further injury.

Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

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? unstageable wound stage III pressure injury stage II wound suspected deep tissue injury

suspected deep tissue injury

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." "This procedure can be safely preformed using clean technique if care is taken not to touch the wound." "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin."

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

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. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. 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.

Clean the wound from the top to the bottom and from the center to outside.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon applying sterile dressings with normal saline over the protruding organs and tissue assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound

applying sterile dressings with normal saline over the protruding organs and tissue