Chapter 8: Skin Integrity and Wound Care (Taylor)

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? a. Deep tissue injury b. Stage 2 pressure injury c. Stage 1 pressure injury d. Unstageable, skin intact

a. Deep tissue injury The nurse should document this finding as a deep tissue injury. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. The description of stage 1 pressure injury includes intact skin with non-blanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound.

The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first? a. Obtain a sterile wound culture. b. Give ciprofloxacin 1 gram IV every 12 hours. c. Consult dietitian to assist client with meal choices. d. Assist client up to chair three times daily.

a. Obtain a sterile wound culture. The nurse should first obtain the sterile wound culture. The culture should be obtained as soon as possible, because it takes time for the results to return and must be done before the nurse can start the ciprofloxacin. Antibiotics interfere with microorganism growth and the primary reason for obtaining a culture is to identify the cause of the infection. Identifying the invading microorganisms helps to determine treatment options and select the most appropriate treatment. The culture should be obtained while the client is in bed; therefore, it should be done before assisting the client up to a chair. Consulting the dietician to assist the client with meal choices should wait until the culture is obtained and the antibiotic is started, because it is of less importance to the well-being and safety of the client.

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? a. Secure the drain to the client's gown with a safety pin below the level of the wound. b. Apply an abdominal binder over the entire wound and drain to support the site. c. Allow the Jackson-Pratt drain to hang freely to avid any kinks in the tubing. d. Tape the drain to the dressing material securely below the level of the wound.

a. 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.

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding? a. Stage 1 pressure injury b. Deep tissue injury c. Unstageable, skin intact d. Stage 2 pressure injury

a. Stage 1 pressure injury This finding should be documented as a stage 1 pressure injury. The description of stage 1 pressure injury includes intact skin with nonblanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound.

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound? a. When the solution from the wound flows out clear b. When the solution from the wound flows out a pink color c. When the solution from the wound flows out a red color] d. When all the irrigation solution is finished

a. When the solution from the wound flows out clear The nurse knows to stop irrigating a wound when the solution from the wound flows out clear. The irrigation removes the exudate and debris, which turns the solution from the wound red to pink to clear, when finished. It is not necessary to use all the solution if the flow is clear already. The nurse should not stop when the return flow is red or pink, this color indicates the wound has not been thoroughly cleaned or irrigated yet.

The nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation? a. Place the client in a sitting position to reduce pressure on the abdomen. b. Assess for pain, shortness of breath, and abdominal pressure. c. Tell the client that this is a life-threatening situation and that the health care provider will be called. d. Leave the wound open and notify the health care provider.

b. Assess for pain, shortness of breath, and abdominal pressure. When excessive drainage appears on the dressing, the nurse would first assess the client for pain, shortness of breath, and abdominal pressure, and then place the client in the supine position to reduce pressure on the abdomen. The nurse would then place a dry, sterile dressing on the wound site and assess vital signs, while reassuring the client that while the wound condition has changed, he/she is all right and the health care provider will be notified immediately.

The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound? a. From the left side of the wound to the right side b. From the upper end of the wound to the lower end c. From the right side of the wound to the left side d. From the lower end of the wound to the upper end

b. From the upper end of the wound to the lower end The nurse would position the client's wound so that the irrigation solution would flow from the upper end of the wound to the lower end. In this way, gravity directs the flow of the liquid from the least contaminated area of the wound to the most contaminated area, thereby decreasing the risk of wound contamination. Directing the flow of irrigating solution from the lower end to the upper end, or from one side to the other side, does not ensure that the solution flows from the least contaminated area to the most contaminated area.

After emptying the drainage from a Jackson-Pratt drain, how will the nurse re-establish suction to the drain? a. Reapply the cap and fully compress the bulb. b. Fully compress the bulb and reapply the cap. c. Turn the suction back on at the wall unit. d. This type of drain does not use suction.

b. Fully compress the bulb and reapply the cap. To re-establish suction after emptying a Jackson-Pratt drain, the nurse should fully compress the bulb and then reapply the cap. Applying the cap before compressing the bulb will not allow the air to escape and, therefore, no suction can be applied. Wall suction is not used with the Jackson-Pratt drain.

The nurse has emptied the drainage from a Hemovac drain. How will the nurse re-establish the suction? a. Recap the drain and keep tubing to gravity. b. Fully compress the drain and reapply the cap. c. Turn the suction back on at the wall outlet. d. Milk and then clamp the drain tubing.

b. Fully compress the drain and reapply the cap. Once emptied, the Hemovac drain should be fully compressed and the cap reapplied while compressed to re-establish suction. Hemovac drains do not use wall suction. Milking and clamping the drain is not appropriate for a Hemovac drain. Recapping the drain without compressing it first will not re-establish the suction.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply. a. Skin around injury is red and warm to touch b. No bone, tendon, or muscle visible. c. Drainage is foul smelling and green in color d. Visible subcutaneous fat e. Full-thickness tissue loss

b. No bone, tendon, or muscle visible. d. Visible subcutaneous fat e. Full-thickness tissue loss The assessment findings which will help the nurse determine the stage of a client's pressure injury are: subcutaneous fat is visible; there is full-thickness tissue loss; and no bone, tendon, or muscle is visible in the wound bed. This information should lead the nurse to document this as a stage 3 pressure injury. The skin being red and warm to the touch and the green foul drainage are indications of wound infection, but do not influence the staging of the client's pressure injury.

The nurse is caring for a Jackson-Pratt drain. Place in order, from first to last, the actions the nurse will perform. Use all options. a. Wipe the outlet of the bulb with a sterile gauze pad. b. Place the graduated collection container under the drain outlet. c. Remove the cap from the bulb. d. Fully compress the bulb. e. Empty the bulb's contents into the collection chamber. f. Replace the cap on the bulb.

b. Place the graduated collection container under the drain outlet. c. Remove the cap from the bulb. e. Empty the bulb's contents into the collection chamber. a. Wipe the outlet of the bulb with a sterile gauze pad. d. Fully compress the bulb. f. Replace the cap on the bulb. When caring for a Jackson—Pratt drain, the nurse should first place the graduated collection container under the drain outlet, then remove the cap from the bulb, and then empty the bulb's contents into the collection chamber, being careful not to contaminate the outlet. Once empty, the nurse should wipe the outlet of the bulb with a sterile gauze pad, fully compress the bulb, and finally, replace the cap on the bulb.

The nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse? a. Change the dressing using sterile technique b. Reinforce the dressing and assess site frequently c. Notify the health care provider of the bleeding d. Call a rapid response and stay with the client

b. Reinforce the dressing and assess site frequently Because bleeding is expected during the first 12 to 24 hours after surgery, the best action by the nurse is to reinforce the dressing and assess the site frequently. Because this is the first surgical dressing that was applied by the surgeon, only the surgeon should change the dressing. Bleeding is expected and, therefore, the health care provider does not need to the notified. Calling a rapid response is not needed in this situation.

The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution? a. Waterproof pad b. Sterile basin c. Gauze d. Used wound dressing

b. Sterile basin When irrigating a client wound, the nurse would place a sterile basin under the wound to protect the client and bed linens from the contaminated solution. The used wound dressing should be immediately discarded after removal and not used to collect solution, because this dressing is contaminated. A waterproof pad would not be used to collect the solution but may be used underneath the basin in case of splashes or spills to prevent soiling the bed linen. Gauze is not used to collect irrigating solution, this would be an expensive choice and does not protect the bed linen.

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development? a. Keep the head of the bed elevated 35 degrees. b. Turn and reposition the client every 2 hours. c. Gently massage any reddened areas for several minutes. d. Pull the client up in the bed very gently.

b. Turn and reposition the client every 2 hours. Pressure injuries are a result of unrelieved pressure that damages underlying tissues. Teaching the caregiver to turn and reposition the client every 2 hours is an important intervention to help prevent unrelieved pressure from causing pressure injury to tissues. Keeping the head of the bed elevated will help to prevent aspiration but does not prevent pressure injury. The caregiver should be taught how to use a draw sheet to lift the client and then move the client up in bed. The client should not be pulled, because this causes a shearing force which can easily injure tissue. Reddened areas should not be massage so this should not be taught to the caregiver.

The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention? a. Use a skin barrier on the wound itself prior to applying a dressing. b. Use Montgomery straps instead of adhesive tape to hold the dressing in place. c. Cleanse the area with an alcohol wipe prior to applying the new dressing. d. Cleanse the area with an antimicrobial wipe prior to applying the new dressing.

b. Use Montgomery straps instead of adhesive tape to hold the dressing in place. When a client's skin around a wound has been irritated by frequent removal of tape, the nurse would consider using Montgomery straps, non-allergenic tape, or dressing ties, instead of adhesive tape, to hold the dressing in place. A skin barrier could also be used on the skin around the wound (not on the wound itself). Alcohol wipes or antimicrobial wipes would not be used, as they would further irritate the skin.

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe? a. Positioning the client to face away from the sterile supplies b. Cleaning the tip of the syringe with an alcohol wipe after each use c. Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound d. Directing the flow of irrigating solution from the top of the wound

c. Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound The best way to prevent contamination of the irrigation syringe is to ensure it never comes in contact with the wound by keeping the tip of the syringe at least 1 in (2.5 cm) above the wound when irrigating the wound. Although the nurse should direct the flow of irrigation from the top of the wound downward, this is not to prevent contamination of the syringe. Positioning of the client is based on wound location not on preventing contamination of the syringe. Cleaning the tip with alcohol wipe after each use is not a recommended way to keep the syringe free of contamination.

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? a. Position the client. b. Maintain a sterile field. c. Raise the bed to elbow height. d. Gather all necessary equipment.

c. Raise the bed to elbow height. The nurse would adjust the bed to a comfortable working position, usually elbow height. Having the bed at the proper height prevents back and muscle strain for the nurse. Maintaining a sterile field prevents risk of infection for the client. Positioning the client is to make the wound accessible for care. Gathering equipment helps the nurse be organized, not prevent injury.

The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse? a. Replace the dressing with a smaller one. b. Allow the wound to air dry. c. Replace the dressing with a larger one. d. Notify the health care provider for further instructions.

c. Replace the dressing with a larger one. When replacing a dressing that has caused blisters on the underlying skin, the nurse would cleanse the area thoroughly, being careful not to aggravate the reddened and blistered areas, and could place a new, larger dressing over the wound so that the blistered area is not further aggravated by tape.

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time? a. Remove the eschar by irrigating with sterile saline. b. Prescribe the client a high carbohydrate diet to promote healing. c. Teach the client ways to relieve the pressure on the heel. d. Teach the client to reposition every 4 hours.

c. Teach the client ways to relieve the pressure on the heel. The best nursing intervention at this time is to teach the client ways to relieve the pressure on the heel to prevent further damage. Stable eschar serves as "the body's natural (biological) cover" and is only removed by health care provider order. Teaching the client to reposition is a good intervention, but the client should be taught to reposition at least every 2 hours. The client would need adequate protein to promote healing, not carbohydrate.

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing? a. To fill the wound with saline to dissolve wound secretions. b. To prevent the dressing from sticking to the wound. c. To promote moist wound healing and protect the wound from contamination and trauma. d. To soften the dressing to prevent trauma to the wound bed.

c. To promote moist wound healing and protect the wound from contamination and trauma. Saline-moistened dressings are used to maintain a moist wound environment to promote moist wound healing and protect the wound from contamination and trauma. A moist wound surface enhances the cellular migration necessary for tissue repair and healing. It is important that the dressing material be moist, not wet, when placed in open wounds. Although a moist dressing may also prevent sticking to the wound, this is not its primary purpose.

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. a. Touch the swab to the intact skin at the wound edges. b. Tap the outside of the culture tube with the swab before placing it in the tube. c. Use the same swab for both wound sites. d. Insert a swab into the wound. e. Press and rotate the swab several times over the wound surfaces. f. Place the swab in the culture tube when done.

d. Insert a swab into the wound. e. Press and rotate the swab several times over the wound surfaces. f. Place the swab in the culture tube when done. The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination.

The nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate? a. Instill 50 mL of normal saline into the wound and loosely cover with packing material. b. Fill the wound with sterile saline gel and cover with a large transparent dressing. c. Insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a moisture-impervious dressing. d. Loosely pack the dampened dressing material to prevent too much pressure on the wound bed.

d. Loosely pack the dampened dressing material to prevent too much pressure on the wound bed. Gently press to loosely pack the moistened gauze into the wound. Avoid overpacking the gauze; loosely pack to prevent too much pressure in the wound bed, which could impede wound healing. The nurse should not instill normal saline or fill the wound with sterile saline gel, as these will not be effective in keeping the wound moist. Inserting rolled gauze into the wound will likely put too much pressure on the wound bed.

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? a. Measure the length, depth, and width of the wound. b. Allow the wound to air dry for 2 minutes. c. Position the client to promote drainage of the solution. d. Pat the wound dry with a sterile gauze sponge.

d. Pat the wound dry with a sterile gauze sponge. The next step after cleaning a client's wound is to dry the wound with a sterile gauze sponge in the same manner in which it was cleaned, moving from top to bottom and from the inside to the outside of the wound. Moisture provides a medium for the growth of microorganisms. The nurse should not air dry the wound but pat it dry with a sterile gauze. Measuring the wound should happen after removing the old dressing. At that time the nurse should assess the wound, wound bed, drainage, and measure the wound. Positioning of the client should happen before beginning the procedure.

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? a. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. b. Assure that the packing material is completely saturated when placed in the wound. c. Use less packing material. d. Reduce the time interval between dressing changes.

d. Reduce the time interval between dressing changes. Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next? a. Assess and clean the wound per orders. b. Identify the client using two client identifiers. c. Twist and break the seal on the culture tube. d. Remove gloves and perform hand hygiene.

d. Remove gloves and perform hand hygiene. After removing the current dressing and discarding it, the nurse should remove the gloves and perform hand hygiene. Then the nurse should apply fresh gloves; sterile gloves may be indicated if the wound edges must be separated to insert the culture swab. After hand hygiene and applying fresh gloves, the nurse would assess and clean the wound using a non-antimicrobial cleanser such as sterile saline, open the culture tube, obtain the culture and complete the procedure. Identifying the client using two client identifiers should happen before the procedure is begun along with explaining the procedure to the client.

How often will the nurse empty a Jackson-Pratt drain? Select all that apply. a. At least every shift b. Only when the drain is full c. Once every 24 hours d. When the drain is one-half to two-thirds full e. At least every 4 hours

d. When the drain is one-half to two-thirds full e. At least every 4 hours The nurse should empty the Jackson-Pratt drain when the drain is one-half to two-thirds full and at least every 4 hours. The nurse should not wait until the drain is full, because this could interfere with the proper functioning of the drain. Once per shift or once per day is not often enough to catch any early indications of a complication.

After assessing a client's Hemovac drain, the nurse prepares to empty it. After emptying the contents into a graduated container, the nurse completes the next steps. Place the steps below in the order in which the nurse would perform them. Use all options. a. Check the patency of the equipment. b. Compress the chamber. c. Wipe the outlet with a gauze pad. d. Apply the cap. e. Secure the device to the client's gown.

c. Wipe the outlet with a gauze pad. b. Compress the chamber. d. Apply the cap. a. Check the patency of the equipment. e. Secure the device to the client's gown. Once the nurse empties the chamber's contents completely into the container, the nurse would use the gauze pad to wipe the outlet. Then the nurse would fully compress the chamber by pushing the top and bottom together with the hands, keeping the device tightly compressed while applying the cap. Next, the nurse would check the patency of the equipment and make sure the tubing is free from twists and kinks. Finally, the nurse would secure the Hemovac drain to the client's gown below the wound with a safety pin, making sure that there is no tension on the tubing.

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options. Irrigate the wound bed. Assess the wound bed. Put on clean gloves. Open dressing materials. Time and date the dressing. Remove old dressing.

1) Put on clean gloves. 2) Remove old dressing. 3) Assess the wound bed. 4) Open dressing materials. 5) Irrigate the wound bed. 6) Time and date the dressing. The nurse should first put on clean gloves, then remove the old dressing, assess the wound bed and surrounding skin, change gloves, open dressing materials, provide the wound care including irrigating the wound bed, then time and date the dressing once completed.

A nurse is gathering the necessary equipment to empty a client's Hemovac drain. Which personal protective equipment (PPE) would be most essential for the nurse to use at a minimum? a. Clean gloves b. Mask c. Gown d. Face shield

a. Clean gloves When emptying a Hemovac drain, it would be most essential for the nurse to put on clean gloves to reduce the risk of exposure to blood and body fluids. Gloves prevent the spread of microorganisms. A mask or face shield would be warranted if there is a risk for splashing. A gown would not be needed.

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure? a. Clean the wound. b. Obtain the wound culture. c. Document the procedure. d. Dress the wound.

a. Clean the wound. To obtain a wound culture, the nurse would first clean the wound, then obtain the wound culture, redress the wound, and document the procedure when complete. Cleaning the wound removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, resulting in inaccurate results.

When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure? a. Date and reuse leftover irrigation solution within 24 hours. b. Pour the chilled irrigating solution into the irrigation container. c. Shake the bottle of irrigating solution before pouring. d. Discard any irrigation solution remaining in the bottle

a. Date and reuse leftover irrigation solution within 24 hours. After setting up a sterile field, if indicated, the nurse pours the warmed sterile irrigation solution into the sterile container. The nurse should date the solution bottle if any solution is leftover and use it within 24 hours. There is no need to shake the irrigating solution. The irrigating solution may be warmed for use but should never be chilled for use. Any solution remaining may be used, if kept in the sterile container, for up to 24 hours; therefore, the nurse should not discard the remaining solution.

The nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation? a. Use small amounts of sterile saline to help loosen and remove the dressing. b. Soak the area with sterile water using gauze pads. c. Wipe the area with an antimicrobial swab and pull the dressing from the skin. d. Wipe the area with an alcohol wipe and pull the dressing from the skin.

a. Use small amounts of sterile saline to help loosen and remove the dressing. If part of the dressing sticks to the skin, the nurse would use small amounts of sterile saline to loosen and remove the dressing. Sterile saline moistens the dressing for easier removal and minimizes damage and pain.

Which client is a greatest risk of developing a pressure injury? a. 17-year-old client postoperative for fracture of the upper extremity b. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness c. 84-year-old client diagnosed with a urinary tract infection who frequently gets out of bed without calling for assistance d. 25-year-old client on bed rest for 24 hours following a procedure

b. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness The 47-year-old client with severe alcoholism (poor nutritional status) and a traumatic brain injury (immobile) is at greatest risk for developing a pressure injury. The 17-year-old does not have any noted risk factors, the 25-year-old is young and only on bedrest for 24 hours so is very unlikely to develop a pressure injury, and the 84-year-old is ambulatory, making them a low risk for a pressure injury. For the 84-year-old client, the greatest risk is for falls.

Which client would be at greatest risk for developing a pressure injury? a. Adolescent client with a cast on the left leg b. Adult client who is comatose c. Client who is delirious after taking pain medications d. Older adult client who has chronic obstructive pulmonary disease (COPD)

b. Adult client who is comatose A client who is comatose is at greatest risk for developing a pressure injury due to the inability to turn or move in bed. This client needs to be turned regularly to prevent development of a pressure injury. The other clients have no restrictions for movement and would not be at great risk for developing a pressure injury. An older client who is bedridden (not a factor with COPD) would also be at high risk for developing a pressure injury due to age-related skin alterations.

How would the nurse secure a Jackson-Pratt drain after emptying it? a. With tape, secure the drain to the client's gown above the wound. b. With a safety pin, secure the drain to the client's gown below the wound. c. With a safety pin, secure the drain to the client's gown above the wound. d. With a safety pin, secure the drain to the side of the bedding.

b. With a safety pin, secure the drain to the client's gown below the wound. After performing drain care, the nurse would secure the Jackson-Pratt drain to the client's gown below the wound with a safety pin, making sure there is no tension on the tubing.

After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the: a. distal to proximal using a new gauze for each wipe. b. top to the bottom using a new gauze for each wipe. c. outside to center using a new gauze for each wipe. d. side to side using a new gauze for each wipe.

b. top to the bottom using a new gauze for each wipe. The nurse would clean the wound from the top to the bottom and from the center to the outside using a new gauze for each wipe. This method ensures that the cleaning is from the least to the most contaminated area and a previously cleaned area is not contaminated again. Cleaning from outside to center, from side to side, or from distal to proximal increases the risk of contaminating the wound as the nurse is starting in the most contaminated area and cleaning into the wound.

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next? a. Assess the drainage for amount, type, color, and odor. b. Dry the wound bed using a sterile sponge. c. Cleanse the wound with a nonantimicrobial cleanser. d. Open the culture tube and apply the swab to the wound bed.

c. Cleanse the wound with a nonantimicrobial cleanser. After removing the old dressing, discarding it, performing hand hygiene and applying fresh gloves, the nurse should cleanse the wound with a nonantimicrobial cleanser to prevent the culture from being contaminated by extraneous wound debris. The assessment of drainage for amount, type, color, and odor should have happened when the nurse removed the old dressing, because the old dressing is part of that information. The wound bed should be dried after the wound is cleaned, not before, and the nurse should not open the culture tube until the wound is cleansed and patted dry.

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound: a. has redness with partial thickness loss of dermis. b. has bright red granulation tissue in the wound bed. c. has black brown eschar covering the top. d. has exposed bone, tendon, or muscle visible.

c. has black brown eschar covering the top. Wounds that have slough (yellow, tan, gray, green, or brown stringy tissue) or eschar covering them are considered unstageable as it is not possible to determine their depth until the slough or eschar is removed. A wound that has exposed bone, tendon, or muscle visible would be considered stage 4. A wound that has redness with partial thickness loss of dermis would be considered stage 2, and a wound with bright red granulation tissue in the wound bed would be considered healing, although there is not enough information to stage this wound.

The nurse is caring for a client with a Jackson-Pratt drain. Which intervention by the nurse is priority before beginning the dressing change? a. Assessing the client's need to void. b. Checking the client's latest laboratory values. c. Gathering the needed supplies. d. Assessing the need for analgesia.

d. Assessing the need for analgesia. Although all noted interventions may be indicated, assessing the need for analgesia is priority. The nurse should administer appropriate prescribed analgesic and then allow enough time for the analgesic to achieve its effectiveness before beginning the procedure.

When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication? a. Sinus tract. b. Ecchymosis. c. Undermining. d. Dehiscence.

d. Dehiscence. Dehiscence is the term for the accidental separation of wound edges, especially a surgical wound. Ecchymosis is discoloration of an area resulting from the infiltration of blood into the subcutaneous tissue. A sinus tract is a cavity or tunnel underneath a wound that has the potential for infection, and undermining occurs when there are areas of tissue destruction underneath intact skin along the margins of a wound.

After emptying a client's Hemovac drain, the nurse re-establishes suction and closes the cap. Which action would the nurse do next? a. Perform hand hygiene. b. Measure the amount of drainage in the graduated container. c. Change the dressing at the drain site. d. Secure the drain to the client's gown

d. Secure the drain to the client's gown After re-establishing suction and closing the cap, the nurse would then secure the drain to the client's gown below the level of the wound. Then the nurse would measure and record the character, color, and amount of the drainage, discard the drainage according to facility policy, remove gloves and perform hand hygiene. Next, the nurse would put on clean gloves and perform drain site care.

The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure? a. The client's temperature and pulses b. Color of drainage on the wound dressings c. Any physical limitations the client may have d. The client's comfort and effectiveness of pain medication

d. The client's comfort and effectiveness of pain medication Prior to cleaning a client's wound, the nurse would assess the client's level of comfort and the need for analgesics before wound care. Wound care may cause pain for some clients. The color of any drainage on wound dressings would be assessed during the wound care procedure. Assessing physical limitations, temperature, and pulses may be appropriate, but these assessments are not directly related to the procedure for cleaning a wound. The procedure for cleaning the wound is the same for a client with or without physical limitations.

The nurse is caring for a client's wound that has a Jackson-Pratt drain in place. What would be the nurse's next step after emptying the chamber's contents into the graduated collection container? a. Replace the cap on the chamber. b. Put on clean gloves. c. Fully compress the chamber. d. Use a gauze pad to clean the outlet.

d. Use a gauze pad to clean the outlet. The order in which the nurse would perform the steps to care for a Jackson-Pratt drain is (1) empty the chamber's contents completely into the container, (2) use the gauze pad to clean the outlet, (3) fully compress the chamber, and (4) replace the cap. Clean gloves would be put on prior to emptying the chamber.

When collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results? a. Back-and-forth motion b. Pushing motion c. Up-and-down motion d. Rolling motion

d. Rolling motion The nurse would insert the swab into the wound and gently roll it over the wound surfaces to obtain a sample of the pathogens causing the infection. Using a pushing motion, up-and-down motion, or back-and-forth motion will not provide the most accurate results according to evidence-based practice and may actually cause injury to the wound tissues.

A client has undergone surgery and has a Hemovac drain in place. When providing care to this client, the nurse would monitor the drain status at which frequency? a. Every 4 hours b. Every 2 hours c. Every 8 hours d. Every hour

a. Every 4 hours The nurse should check the drain status every 4 hours. Checking the drain ensures proper functioning and early detection of problems. The nurse should empty and reengage suction (compress device) when device is half to two-thirds full. The nurse should check all wound dressings at least every shift.