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

Assess the client's wound and vital signs. Explanation: First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, pp. 1116-1121.

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? -Red classification -Unstageable -Black classification -Yellow classification

Black classification Explanation: A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1063.

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 newborn -a client with cardiovascular disease -an older client with arthritis -a critical care client

a critical care client Explanation: Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1054.

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

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." Explanation: Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue. As such, clients should be taught to avoid soaps with artificial ingredients or fragrances, as these may be harsher on the skin. It is good to be clean; however, advice of taking at least two showers per day is excessive and may dry the skin. Moisturizer should be applied to the skin following bathing to prevent dryness of the skin. Drinking water is important to remain hydrated; however, the nurse should recommend drinking 1,500 to 2,000 mL of water daily. Drinking 8 ounces three times a day is 720 mL.

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

"Do you experience incontinence?" Explanation: The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1054.

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." -"I can let this stay on my ankle an hour at a time." -"I must wait 15 minutes between applications of cold therapy." -"I should keep this on my ankle until it is numb."

"I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1087.

The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? -"Drainage will occur by gravity and capillary action." -"The bulb-like system will stay in place permanently after your mastectomy." -"It provides a way to remove drainage and blood from the surgical wound." -"You will receive medication through this device."

"It provides a way to remove drainage and blood from the surgical wound." Explanation: The bulb-like drain allows the 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1080.

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." -"That is called slough, and it will usually fall off." -"This is normal tissue." -"You are seeing undermining, a type of tissue erosion."

"Necrotic tissue is devitalized tissue that must be removed to promote healing." Explanation: The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1057.

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? -"That is old clotted blood underneath the wound" -"That is called undermining, a type of tissue erosion." -"That is necrotic tissue, which must be removed to promote healing." -"This is normal tissue."

"That is necrotic tissue, which must be removed to promote healing." Explanation: Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1071.

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

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, table 32-4 Common types of drains, p. 1064.

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?(includes picture) -"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." -"Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." -"This procedure can be safely preformed using clean technique if care is taken not to touch the wound." -"Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin."

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." Explanation: The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Skill 32-2, p. 1099.

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

"Very little scar tissue will form." Explanation: Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1050.

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

"Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1084.

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. -"The margins of your wound are widely separated." -"This is a simple reparative process." -"Your wound will be purposely left open for a time." -"Very little scar tissue will form." -"Your wound edges are right next to each other."

-"Very little scar tissue will form." -"This is a simple reparative process." -"Your wound edges are right next to each other." Very little scar tissue is expected to form during first-intention healing in a wound whose wound edges are close to each other. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1048.

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. -Decreased radial pulse -Fingers with quick capillary refill -Cyanosis -Warm hand -No finger numbness or tingling

-Fingers with quick capillary refill -Warm hand -No finger numbness or tingling Explanation: The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers. Cyanosis, pallor, coolness, numbness, tingling, swelling, or absent or diminished pulse are signs that circulation may be decreased or that nerve function is impaired. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, table 32-2 factors Placing a Person at risk for Skin Alterations, p. 1046.

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

-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. Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, pp. 1112-1116.

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

-an adolescent with multiple body piercings -a client receiving radiation therapy -a client with diabetes Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a sexual relationship with multiple gay male partners would also place a client at risk for HIV and skin alterations, but this client is in a monogamous relationship. Cardiac monitoring does not place a client at risk for skin alterations. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1046.

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. -turn the client every 2 hours when the client is in bed -elevate the head of the bed 90 degrees four times daily -provide incontinent care every 2 hours and as needed -encourage the client to take fluids every 2 hours -pull the client up in bed as needed

-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 Explanation: Nursing interventions that will decrease the risk of pressure injury development include incontinent care every 2 hours and as needed, turning the client every 2 hours, and encouraging fluids every 2 hours. Factors that lead to pressure injury development include external pressure, friction, shear, immobility, inadequate nutrition and hydration, skin moisture, mental status, and age. Elevating the head of the bed 90 degrees four times daily increases pressure to the coccyx and sacral area and causes shearing. Pulling a client up in bed as needed should be avoided, as this causes shear. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1081.

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 Penrose drain has a small bulblike collection chamber that is kept under negative pressure. -A Penrose drain is a closed drainage system that is connected to an electronic suction device. -A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

A Penrose drain promotes passive drainage into a dressing. Explanation: A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1079.

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

An infant's skin and mucous membranes are easily injured and at risk for infection. Explanation: An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1045.

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

Apply a skin protectant to the skin around the incision. Explanation: Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1082.

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

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, pp. 1096-1100.

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. -Pack the wound with gauze pads and a dry sterile dressing. -Inform the client that this is an expected occurrence and not to worry. -Allow the wound and intestinal contents to remain open to air.

Apply saline solution-moistened gauze over the protruding area. Explanation: The first thing the nurse will do is cover the protruding intestine with a saline solution-moistened gauze. The nurse will then notify the health care provider of wound evisceration. If the protruding intestine is left open to the air, it may cause drying of the fragile tissue and necrosis to the area. The nurse should not pack anything into the wound since foreign body retention may cause complications at a later time if the gauze is not recovered. The occurrence of wound evisceration is not an expected finding and may be serious depending upon whether the protruding area is viable. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Cleaning the Wound, p. 1075.

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? -Glasgow scale -Braden scale -FLACC scale -Morse scale

Braden scale Explanation: The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glasgow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1065.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? -Use clean technique to clean the wound. -Clean the wound in a circular pattern, beginning on the perimeter of the wound. -Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. -Clean the wound from the top to the bottom and from the center to outside.

Clean the wound from the top to the bottom and from the center to outside. Explanation: Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, pp. 1096-1100.

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

Connective tissue Explanation: Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1042.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? -Infection of the wound -Dehiscence of the wound -Evisceration of the viscera -Herniation of the wound

Dehiscence of the wound Explanation: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the health care provider. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1053.

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

Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1050.

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

Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1050.

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings? -Diffuse dermatitis accompanied by pruritus -Diffuse fungal infection accompanied by pruritus -Superficial abscess accompanied by pruritus -Superficial contusion accompanied by pruritus

Diffuse dermatitis accompanied by pruritus Explanation: The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching. A contusion is a closed wound with bleeding in underlying tissues from a blunt blow. Fungal infections do not cause a rash or itching. An abscess is a localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Nursing Strategies to Address age-related Changes in Skin, p. 1047.

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings? -Diffuse fungal infection accompanied by pruritus -Superficial contusion accompanied by pruritus -Superficial abscess accompanied by pruritus -Diffuse dermatitis accompanied by pruritus

Diffuse dermatitis accompanied by pruritus Explanation: The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching. A contusion is a closed wound with bleeding in underlying tissues from a blunt blow. Fungal infections do not cause a rash or itching. An abscess is a localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Nursing Strategies to Address age-related Changes in Skin, p. 1047.

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

Discontinue the therapy and assess the client. Explanation: The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1087.

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

Discontinue the therapy and assess the client. Explanation: The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1087.

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? -Notify the wound care nurse. -Contact the health care provider. -Document the findings. -Change the dressing.

Document the findings. Explanation: The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is no need to contact the health care provider or the wound care nurse. The nurse should not change the surgical dressing. Most often, the surgeon will change the first dressing in 24 to 48 hours. For this reason, the wound care nurse does not need to be notified. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, pp. 1100-1101.

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 -Every 25 to 36 hours -Every 12 to 24 hours -Every 8 to 12 hours

Every 48 to 72 hours Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, pp. 1116-1121.

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 -Green beans -Pasta salad -Banana

Fish Explanation: To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Box 32.1, p. 1049.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? Keep the swab and the inside of the culture tube sterile prior to collecting the culture. -Utilize the culture swab to obtain cultures from multiple sites. -Cleanse the wound after obtaining the wound culture. -Stroke the culture swab on surrounding skin first.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture. Explanation: The swab and the inside of the culture tube should be kept sterile prior to the procedure. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1112.

When applying an external heating pad, which prescription from the health care provider would the nurse question? -Maintain the temperature between 105°F to 109°F (40.5°C to 43°C) -Use gauze to secure the heating pad to the site of application -Leave heating pad on for 45 minutes -Assess site frequently during application of the heating pad

Leave heating pad on for 45 minutes Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Skill 32-8 Applying an External Heating Pad, pp. 1121-1124.

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? -Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. -Carefully pick the crusts off the sutures with the forceps before removing them. -Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. -Do not attempt to remove the sutures because the wound needs more time to heal.

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1082.

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? -Notify the surgeon STAT -Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon -Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon -Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Explanation: With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration. Approximating the wound edges and applying wound closure tapes may cause the client undue pain and trap bacteria in the wound. Irrigating the open wound may cause unwanted bacteria from the surrounding area to wash into the wound. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Skill 32-2, p. 1096.

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 the supine position with a pillow under the knees -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 -Placing the client in a wheelchair with the back of the feet resting against the heel loops -Placing the client in a side-lying position with a pillow between the lower legs

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 Explanation: Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues. Pressure points in bed vary depending on the size and shape of client and the position. Pressure points while sitting in a chair or wheelchair also vary depending of the style, shape, and construction of the chair or wheelchair, the clients position in the chair, and the size and shape of the client. Any boney prominence or areas under a large amount of pressure against a hard or semihard surface can create a pressure injury. To protect clients at risk for pressure injury, the nurse implements a 2-hour turn schedule, uses a pressure redistribution support surface, keeps pressure points from pressing on the bed or chair by using positioning devices or pillows, keeps boney prominences from rubbing on each other, minimizes exposure of skin to incontinence, perspiration, or wound drainage, and provides adequate calories and nutrients. A pillow placed between the lower legs in side-lying position will prevent ankle to ankle pressure, but not ankle to mattress pressure. Placing a pillow under the knees while positioned supine will increase pressure on the heels. While using a wheelchair, it is best to have the client wear well-fitted shoes and position the feet on the footplate and remove the heel rest or heel loop. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Muscle Mass, Tone, and Strength, p. 1149.

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? -Yellow -Red -Blue-grey -White

Red Explanation: Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1053.

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

Secure the drain to the client's gown with a safety pin below the level of the wound. Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, pp. 1106-1108.

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 IV -Stage I -Stage III -Stage II

Stage II Explanation: A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1056.

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? -Stop removing staples and apply an abdominal pad over the incision. -Stop removing staples and inform the surgeon -Apply an occlusive pressure dressing after removing the staples. -Apply adhesive wound closure strips after each staple is removed.

Stop removing staples and inform the surgeon Explanation: If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1082.

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 -Dermis -Muscle layer -Epidermis

Subcutaneous tissue Explanation: The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1044.

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? -Cutting with a sharp instrument with wound edges in close approximation with correct alignment -Puncture of the skin -Tearing of a structure from its normal position -Tearing of the skin and tissue with some type of instrument; tissue not aligned

Tearing of a structure from its normal position Explanation: An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1048.

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 carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain. -The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain. -The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain.

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. Explanation: Sometimes the health care provider orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1079.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? -The nurse uses wet-to-dry dressings continuously. -The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. -The nurse packs the wound cavity tightly with dressing material. -The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. Explanation: A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1072.

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 a ring cushion to protect reddened areas from additional pressure. -The nurse increases the amount of time the head of the bed is elevated. -The nurse elevates the foot of the bed. -The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. Explanation: Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1070.

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

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. Explanation: Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1070.

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 swabs the wound with povidone-iodine to fight infection in the wound. -The nurse swabs the wound from the bottom to the top. -The nurse uses friction when cleaning the wound to loosen dead cells.

The nurse works outward from the wound in lines parallel to it. Explanation: A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1076.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? -The wound is 3 × 5 cm, with yellow tissue covering the entire wound. -The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. -The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. -The wound is a 3 × 5-cm blood-filled blister

The wound is 3 × 5 cm, with yellow tissue covering the entire wound. Explanation: The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1084.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? -To turn the head away from the area whenever coughing -To ambulate using a cane or walker -To remain in bed for the next 4 hours -To splint the area when engaging in activity

To splint the area when engaging in activity Explanation: To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1082.

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. 1Place the drape to cover the wound and an additional 3 to 5 cm. 2Use sterile gloves. 3Ensure that negative pressure has been achieved. 4Cut a 2-cm hole in the drape. 5Cut the foam to the shape and measurement of the wound. 6Apply a vacuum device to wound.

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. Explanation: The correct order for the application of negative pressure wound therapy is as follows: apply 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 vacuum device to the wound; and ensure that negative pressure has been achieved. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1079.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? -a client who lifts himself up on the elbows -a client who must remain on the back for long periods of time -a client who lies on wrinkled sheets -a client sitting in a chair who slides down

a client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure injury from shearing forces would be a client sitting in a chair who slides down. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1055.

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 immobility. -a rash related to a yeast infection. -an allergic reaction to medications. -an allergic reaction to detergent.

a rash related to a yeast infection. Explanation: Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1046.

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 small plastic ruler -an otic curette -a sterile, flexible applicator moistened with saline -a sterile tongue blade lubricated with water soluble gel

a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1107.

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 wound healing naturally that becomes infected. -a wound left open for several days to allow edema to subside -a large wound with considerable tissue loss allowed to heal naturally

a surgical incision with sutured approximated edges Explanation: Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1048.

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site? -a gauze dressing precut halfway to fit around the IV line -a gauze dressing premedicated with antibiotics -a dressing with a nonadherent coating a transparent film

a transparent film Explanation: Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protect the site from microorganisms. Gauze dressings—precut, with an adherent coating, premedicated with antibiotics—do not allow the nurse to visualize the site without partially or completely removing the dressing. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1072.

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? -gauze -transparent -hydrocolloid -adhesive strips with eyelets

adhesive strips with eyelets Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1076.

The client has a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen. Which nursing concern will the nurse identify for this client's care plan? -infection risk due to wound -altered skin integrity due to open wound -knowledge deficiency regarding wound care related to laceration -pain due to wound sustained by knife

altered skin integrity due to open wound Explanation: Altered skin integrity best describes the minor laceration. Although the other nursing concerns of pain, knowledge deficiency, and infection risk are possible as a result of the laceration, there is no indication in the scenario that they are the case. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1048.

The nurse has delegated applying an elastic bandage with clips to the right knee of a 12-year-old client to the unlicensed assistive personnel (UAP). Which action will the nurse determine the UAP needs additional training? -used metal clips to secure end of bandage -keeps bandage free of wrinkles -applies wrap from proximal to distal direction -uses a figure-of-8 technique

applies wrap from proximal to distal direction Explanation: A roller bander or elastic bandage with clips should be applied from a distal to proximal direction. The other actions are all correct steps to use to apply a bandage, especially to the knee. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Securing Wound Dressings, p. 1077.

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 -monitoring for pallor and mottled appearance of the wound -assessing for impaired blood flow to the area of evisceration. -contacting the surgeon

applying sterile dressings with normal saline over the protruding organs and tissue Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1053.

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 the wound from the outer area toward the inner area -cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing -cleanse the wound in parallel strokes from the top to the bottom of the wound -cleanse with a new gauze for each stroke

cleanse with a new gauze for each stroke Explanation: When cleansing a wound, the nurse should use a new gauze or swab on each downward stroke of the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1098.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? -antihypertensive drugs -corticosteroids -potassium supplements -laxatives

corticosteroids Explanation: Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1052.

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

dehiscence. Explanation: Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1053.

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? -exerting equal, but not excessive, tension with each turn of the bandage -elevating and supporting the stump -wrapping distally to proximally -keeping the bandage free of gaps between turn

elevating and supporting the stump Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1077.

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

eschar. Explanation: The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1051.

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

evisceration Explanation: Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1053.

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

figure-of-eight turn Explanation: A figure-of-eight turn is used for joints like the elbows and knees. The other answers are incorrect. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1077.

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? -alginate -transparent film -hydrocolloid -hydrogel

hydrocolloid Explanation: Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1073.

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? -biosurgical debridement -enzymatic debridement -autolytic debridement -mechanical debridement

mechanical debridement Explanation: Mechanical debridement involves physical removal of necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1072.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: -prickly heat. -milia. -acne vulgaris. -lanugo.

milia. Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1047.

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

preventing the client from sliding in bed Explanation: Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue. Pulling up from under the arms and pulling the sheets to reposition the client cause shearing force. Improving the client's hydration status could help with wound healing, but not in the prevention of shearing force. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1055.

The nurse is preparing a discharge plan for an older adult client who recently underwent a hernia repair. Which action should the nurse include in the care plan to assist with this client's recovery? -encourage the client to spend time at an assisted living facility before returning home -provide neighbors with proper education to provide care -inspect the home for potential safety issues -refer the client to a local group which provides home-delivered meals

refer the client to a local group which provides home-delivered meals Explanation: Several factors are known to delay healing in older adults related to age-related changes. One of those is inadequate nutrition, which can be related to poor appetite or physical or economic barriers. Referring the client to a local community agency which provides home-delivered meals would be an option to assist with this. It would be unethical for the nurse to try to talk the client into doing something not necessary or wanted. The nurse should function as an advocate, not insist the client follow the nurse's opinion. The nurse should only include neighbors if the client indicates this is desired. Including the neighbors without the consent of the client would be a breach of confidentiality. The nurse may refer the client for visits from a home health nurse who would be the one to conduct a safety inspection. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care.

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 -primary intention -maturation -tertiary intention

secondary intention Explanation: Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1075.

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? -serous -serosanguineous -purulent -sanguineous

serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink or pink-yellow. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Drainage, p. 1063.

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 -sanguineous -purulent -serous

serosanguineous Explanation: This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1063.

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 I -stage IV -stage III -stage II

stage II Explanation: The area of redness and blister formation indicate that the client is experiencing a stage II pressure injury. A stage I pressure injury is intact but reddened. A stage III pressure injury has a shallow skin crater that extends to the subcutaneous tissue. A stage IV pressure injury is severe; the tissue is deeply ulcerated and exposes muscle and bone with the presence of necrotic tissue likely. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Figure 32-19. Wound and skin assessment/documentation tool., p. 1084.

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 III -stage IV -stage I -stage II

stage II Explanation: The area of redness and blister formation indicate that the client is experiencing a stage II pressure injury. A stage I pressure injury is intact but reddened. A stage III pressure injury has a shallow skin crater that extends to the subcutaneous tissue. A stage IV pressure injury is severe; the tissue is deeply ulcerated and exposes muscle and bone with the presence of necrotic tissue likely. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, Figure 32-19. Wound and skin assessment/documentation tool., p. 1084.

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 I -stage IV -stage II -stage III

stage IV Explanation: Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1058.

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

stage IV Explanation: Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1058.

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. -to decrease dead space by decreasing drainage. -to provide a sinus tract for drainage. -to divert drainage to the peritoneal cavity.

to provide drainage for bile. Explanation: A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1064.

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? -hydrocolloid -transparent -gauze -adhesive strips with eyelets

transparent Explanation: Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1073.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? -use pillows to maintain a side-lying position as needed -elevate the head of the bed 90 degrees -place a foot board on the bed -provide incontinent care every 4 hours as needed

use pillows to maintain a side-lying position as needed Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 32: Skin Integrity and Wound Care, p. 1091.