Fundamentals Nursing Prep U Chapter 31 Skin Integrity & Wound Care

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

Pressure ulcers are caused by unrelieved compression of the skin that results in damage to underlying tissues.

True

A nurse is caring for a client with a nonhealing stage IV pressure ulcer. 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

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment?

"Do not douche 24-48 hours before the procedure."

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

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."

The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate?

"Wounds heal better when a moist wound bed is maintained."

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate?

"You will likely experience periods of increased skin outbreaks and periods of remissions."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

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

A client has a fissure on her finger due to chafing. The client asks "How long will it be painful?" The nurse explains that the inflammation phase will last:

3 days

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains?

A Penrose drain promotes drainage passively into a dressing.

A nurse is caring for a client who has a 6-cm × 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 best to be ordered by the primary care provider?

Alginate

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 ulcer development?

Braden scale

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure?

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

Which is not considered a skin appendage?

Connective tissue

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 measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth

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 client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication?

Evisceration

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse to select to promote wound healing?

Fish

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

Gauze

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Reassess the coccyx area for fading of the redness in 60 to 90 minutes.

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 of the following actions should the nurse perform in obtaining a wound culture?

Keep the swab and inside of the culture tube sterile.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

Local capillary pressure must be lower than external pressure.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

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

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

The nurse is caring for a 7-year-old who suddenly developed difficulty hearing out of the left ear. Which nursing action is appropriate?

Perform a thorough inspection of the ear.

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 the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize with this client's wound?

Proliferation Phase

A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain?

Provides drainage for bile

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage?

Serosanguineous

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

True

While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record?

Unintentional, partial-thickness wound

`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 ulcer?

Use pillows to maintain a side-lying position as needed.

The nurse is caring for a client who has recently noted abnormal pigmentation in his skin. What is most likely deficient in the client's diet?

Zinc

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 in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

A client's risk for the development of a pressure ulcer 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

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

dehiscence.

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar.

What is the best nursing diagnosis to describe a minor laceration to finger sustained when a client was cutting fruit in the kitchen with a knife?

impaired skin integrity related to open wound

A skin infection caused by beta-hemolytic streptococci common in children is:

impetigo

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

In the older adult client, wrinkling is related to:

loss of elasticity

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

milia

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 describes this?

secondary intention

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

to apply sunscreen when exposed to ultraviolet rays.

A nurse is caring for a client who had an appendectomy and has been readmitted for wound care. The incision has been opened by the primary care provider to allow for drainage. The wound is draining copious amounts of yellow exudate. Which type of dressing will the nurse apply to the wound? Select all that apply.

• Alginates • Antimicrobials • Composites

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.

• Cover wound with a gauze moistened with normal saline. • Place client in low-Fowler's position. • Use sterile techniques.

The nurse is performing an admission assessment on a client being admitted to a long-term care facility. The nurse notes the client has a history of psoriasis. Which locations on the body is the nurse most likely to find manifestations consistent with the condition? Select all that apply.

• Elbows • Knees • Soles of the feet

Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a client's wound? Select all that apply.

• Position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. • Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. • Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces.

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? Select all that apply.

• Use whirlpool treatments, if ordered, until the ulcer is considered clean. • Keep the ulcer tissue moist and the surrounding skin dry. • Use a dressing that absorbs exudate but maintains a moist healing environment.

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply.

• The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. • a wound that does not feel hot and tender upon palpation • a wound that forms exudate due to the inflammatory response

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply.

• The nurse makes more frequent checks of the skin of an older adult using a heating pad. • The nurse fills an ice bag with small pieces of ice to about two-thirds full. • The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm.

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."

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include?

"It is important to keep your sutured incision clean."

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 nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?

"Steri-Strips will hold my wound together until it heals."

The spouse of a client limps into the emergency department and states, "I stepped on a nail and didn't have shoes on. Now I can barely walk." What type of injury does the nurse anticipate?

puncture

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

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

second degree or partial thickness

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline

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

a surgical incision with sutured approximated edges

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?

period during which the wound undergoes changes and maturation

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention

The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot, and injured the worker's foot. What type of injury does the nurse anticipate?

puncture

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage?

under the client

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

Apply sterile dressings with normal saline over the protruding organs and tissue.

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

Serosanguineous

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?

Soak in a warm bath for drainage.

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

Stage II

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

Stage III

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury?

Stage IV

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Support the client from sliding in bed.

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

Tearing of a structure from its normal position

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

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

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces?

a client sitting in a chair who slides down

An older adult client is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply.

• "It may take you longer to heal than someone younger." • "Eat nourishing foods after surgery to promote healing." • "Wound healing can take longer if you have been exposed often to the sun." • "Monitor your moods after surgery. Depression after surgery is not normal."

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

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

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound?

Secondary intention

The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What is the appropriate nursing response? Select all that apply.

• "Medical maggots are sterilized before they are introduced to the wound." • "I understand your concern; let's talk further about your thoughts about this treatment." • "The choice regarding whether to have or decline this treatment is yours."

The wound care nurse is performing assessment of clients. Which wound complications does the nurse report to the health care provider? Select all that apply.

• partial disruption of wound layers • viscera protruding through the incisional area • a wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5 • fistula formation