Chapter 32: Skin Integrity and Wound Care

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.

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage.

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

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change.

Use sterile gloves. Cut the foam to the shape and measurement of the wound. Place the drape to cover the wound and an additional 3 to 5 cm. Cut a 2-cm hole in the drape. Apply a vacuum device to wound. Ensure that negative pressure has been achieved.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

cleanse with a new gauze for each stroke

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

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 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?

mechanical debridement

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

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.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

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 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?

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

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."

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel.

The nurse is preparing to change a large abdominal dressing in which blood and drainage is expected. In addition to gauze, which dressing supply will the nurse gather to take in the client's room?

adhesive strips with eyelets Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Transparent dressings are used to protect intravenous insertion sites. Hydrocolloid dressings are used to used keep a wound moist. Gauze dressings absorb blood or drainage; however, they are not suited to a large wound.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?

Supports the area around the wound

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 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

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making?

The nurse should apply adhesive wound closure strips after removing staples.

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

a surgical incision with sutured approximated edges

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?

incision

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound?

proliferation phase The wound description reveals a beefy red wound bed that bleeds easily. This is the proliferation stage and describes granulation tissue. Hemostasis is the initial phase, involving activation of platelets. In the inflammatory phase, white blood cells and macrophages enter the wound to remove debris. The maturation phase involves collagen remodeling and scar formation.

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 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." The bulb-like drain allows removal of blood and drainage from the surgical site. Drainage in this system is aided by low suction, not by gravity or capillary action. It does not provide a route for medication administration, nor does it stay attached permanently.

The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply.

Fill the bowl of the sitz bath about halfway full with tepid to warm water. Insert tubing into the infusion port of the sitz bath. Slowly unclamp the tubing and allow the sitz bath to fill. Ensure that the call bell is within reach.

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain?

Secure the drain to the client's gown with a safety pin below the level of the wound. To ensure there is not any tension on the tubing of a Jackson-Pratt drain, the nurse should secure the drain to the client's gown with a safety pin below the level of the wound. Taping the drain or applying an abdominal binder will keep the bulb compressed and hinder the suction action of the drain. The drain should not be allowed to hang freely because this causes tension on the drain site.

A client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues?

applying the dressing with a binder

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."

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."

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 client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Penrose drain Penrose drains are commonly used after a surgical procedure or to drain an abscess. Jackson-Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is typically placed into a vascular cavity where blood drainage is expected after surgery, and wound pouching is used on wounds that have excessive drainage.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

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

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 caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?

undermining

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 caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document?

Black classification

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

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

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.

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

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

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?

avulsion n avulsion involves the stripping away of large areas of tissue, leaving cartilage and bone exposed. Therefore the nurse will document this assessment finding as an avulsion. A puncture is an opening of the skin caused by a narrow, sharp, pointed object. A laceration is the separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore the nurse would not document the finding as a puncture, laceration, or contusion.

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?

secondary intention

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?

Implement a 2-hour repositioning schedule

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

dehiscence.

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?

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

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 Because activity of the sebaceous and sweat glands decreases, the skin will become dryer and the client may have pruritis. The perineal area should be washed daily but the nurse should avoid full bathing of the body on a daily basis. Harsh soaps should be avoided and only used sparingly. The fluid intake should be increased unless otherwise contraindicated by medical condition. Pressure points are not related to the action of sebaceous and sweat gland activity, but the pressure points should be checked for redness after 30 minutes.

When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse?

Document the findings. The nurse should document the findings. The red tissue that bleeds easily is granulation tissue, a key part of the healing process. As the wound is healing, there is no need to contact the physician or the wound care nurse. There is also no need to send the client to the emergency room.

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 Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors.

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.

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

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

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 The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

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

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?

reposition the safety pin or clip on the drain

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 a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?

stage III Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage. Stage IV exposes muscle and bone. Reference:

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 A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial-thickness loss of dermis that often presents as an open blister. A stage III pressure injury is a full-thickness tissue loss in which subcutaneous tissue is visible. An unstageable wound is covered by slough or eschar. The depth of the wound is unknown because of this covering.

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 should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. A hydrocolloid dressing helps keep the wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

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 providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice?

It is appropriate to use clean technique during this procedure. Chronic wounds and pressure injuries may be treated using clean technique; aseptic technique is not always necessary. Disinfectants are not normally applied to wound beds except in exceptional circumstances.

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 two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action?

Recompress the drain before replacing the cap.

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

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

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed

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

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."

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps. Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps.

A nurse is providing wound care for a client who has a pressure injury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options.

Give pain medication. Use nonsterile gloves. Remove old dressing. Apply sterile gloves. Cleanse the wound with normal saline. Apply wound covering.

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 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.

What should the nurse assess before application of sitz bath therapy? Select all that apply.

Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

Every 48 to 72 hours In a non-infected wound, the negative pressure dressing should be changed every 48 to 72 hours. The negative pressure wound therapy should not be disturbed or interrupted more often than that unless the wound is infected. Infected wounds may require dressing changes every 12 to 24 hours.

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.

Which client(s) is considered at risk for skin alterations? Select all that apply.

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

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

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." This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad?

105°F to 109°F (40.5°C to 43°C)

For which client would the application of a hydrocolloid dressing be most appropriate?

A client who has a partial-thickness venous ulcer with moderate drainage Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; they are appropriate for partial- and full-thickness wounds with light to moderate drainage. A sunburn would not normally warrant this type of wound dressing and they are not used on infected wounds. Hydrocolloid dressings are not used on uncomplicated surgical incisions.

An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor?

Adipose tissue is poorly vascularized.

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.

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. Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

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?

As a stage I pressure injury

A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For which type(s) of injury would the nurse be alert? Select all that apply.

Broken left ankle Abrasions Soft tissue damage Concussion Bruising

A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options.

Clean the incision using the wound cleanser and gauze. Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. Using the scissors, cut one side of the suture below the knot, close to the skin. Grasp the knot with the forceps and pull the cut suture through the skin. Remove every other suture to be sure the wound edges are healed. Apply adhesive closure strips.

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. When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

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 who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

Document the findings.

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select?

Hydrocolloid The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement. Telfa pads are nonstick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement.

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 preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?

Impaired tissue integrity Using the A, B, C (Airway, Breathing, Circulation) mnemonic, impaired tissue integrity takes priority. Using Maslow's Hierarchy of Needs, impaired tissue integrity also takes priority. Disturbed body image, knowledge deficit, and acute pain are all important issues that need to be addressed, but ensuring there is proper circulation to the surgical area, the surgical area is free of signs of infection, and the surgical area is intact is priority.

Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan?

Record the quantity of drainage once per shift and document on the intake and output record. Output from NPWT should be recorded once per shift. Leaks can often be resolved by reinforcing the dressing and the treatment should continue 24 hrs/day. Dressings are normally changed two to three times per week.

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 client receiving a sitz bath starts complaining of light-headedness to the nurse. What is the nurse's most appropriate action?

Stop the sitz bath and call for help

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action?

Stop the sitz bath, call for help, and help the client to the toilet to sit down.

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

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 Chances are the client knows that stepping on a nail could lead to a serious complication or illness, even if the client cannot remember or does not know about tetanus or infections. How to care for the wound is usually something clients will want to know before being discharged. The client in this scenario is reporting pain, so pain control will be one of the concerns. It is unlikely that the client will be worried about scarring on the bottom of the foot or sutures due to it being a puncture. The client is still walking, although in pain and with a limp, it would be unlikely the client would be concerned about being able to walk. More than likely, the client has already figured out the injury may not have occurred or would not be as bad had he or she been wearing shoes, so the nurse would not anticipate the need for preventative education.

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.

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?

The status of the client's tetanus immunization

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention?

Use clean technique instead of sterile technique if the wound is closed. Clean technique can be used on a closed wound. When the solution from the wound turns clear, the irrigation should be discontinued. If bleeding is noted that was not previously there, the nurse should stop the irrigation and notify the health care provider. There is no need to apply petroleum jelly to the periwound skin.

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?

Wound irrigation With the yellow classification using the RYB wound classification system, wound irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present.

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:

a rash related to a yeast infection.

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 Alginate dressings contain alginic acid from brown seaweed. Covered in calcium-sodium salts, they absorb exudate, maintain a moist wound environment, and facilitate autolytic debridement. A secondary dressing is required to secure them. Transparent film allows frequent assessment of the site but provides a barrier. A hydrogel dressing comprises an 80%-99% water base and is used with partial- and full-thickness wounds. An antimicrobial dressing has an antibiotic that reduces bacterial growth.

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 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 placing the client in the low Fowler position using sterile technique

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 Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing.

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 Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.

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

milia. Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.

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.

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 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.

A nurse applies an aquathermia pad to the back of a client with arthritis. What administration considerations should the nurse use? Select all that apply.

Apply a bath blanket over the aquathermia pad. Assess skin and pain level at baseline and ongoing. Check the water level in the aquathermia unit periodically. The nurse would apply a bath blanket over the aquathermia pad to protect skin from direct contact with the heat source. Distilled water is used to the fill mark in the unit. Tap water should not be used because it leads to mineral deposits, making the machine not function properly. The heat therapy is prescribed for a certain time, usually up to 30 minutes, and then it needs to be removed for the prescribed time to prevent the development of rebound phenomenon, when excessive heat leads to tissue congestion and vasoconstriction. Leaving heat therapy in place too long also can lead to skin burns and tissue damage. The nurse would assess skin and pain level at baseline and ongoing throughout the therapy before and after application of the treatment. The aquathermia unit provides moist heat, so the nurse would check the unit to ensure that the water level is at the correct level so the matching works properly. If the water drops below its required level, permanent damage may occur.

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.

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. A client with diarrhea caused by Clostridium difficile is at risk for dehydration. As such, the priority assessments should include intake and output, skin turgor, condition of mucous membranes, and vital signs. Assessing the coccyx area for blanching should be done with shift assessments; however, circulating fluid volume takes priority. Monitoring for nausea and assessing the client's mentation is not directly related to the effects of the infectious diarrhea.

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

The client has fistula formation. A fistula is an abnormal tubelike passageway that forms from one organ to outside the body. There is no information that would lead to a suspicion that the wound is infected. Wound dehiscence would be indicated by separation of the wound and evisceration would be evidenced by protrusion of abdominal contents through the wound.

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

Leave heating pad on for 45 minutes The nurse should question the prescription to leave the heating pad on for 45 minutes, because this is too long and could cause complications such as burns. The maximum time limit should be no more than 30 minutes. Using heat for more than 30 minutes can result in tissue congestion, vasoconstriction, and increases the risk of tissue damage. It is important for the nurse to frequently assess the site during the application to ensure no adverse affects are occurring. The nurse should use either gauze or tape to hold the heating pad in the correct location; however, pins should not be used as they may puncture and damage the pad. The temperature should be maintained between 105°F to 109°F (40.5°C to 43°C) to ensure the best therapeutic results.