Prep U Chapter 32: Skin Integrity and Would Care

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? a. As a stage I pressure injury b. As a stage II pressure injury c. As a stage III pressure injury d. As a stage IV pressure injury

a. As a stage I pressure injury

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. a. Clean the wound from top to bottom. b. Clean from the outside of the wound to the center. c. Use a sterile applicator to apply any ointment that is ordered. d. Use a new gauze for each wipe of the wound. e. Avoid touching the wound bed, whether with gloves or forceps.

a. Clean the wound from top to bottom. c. Use a sterile applicator to apply any ointment that is ordered. d. Use a new gauze for each wipe of the wound. e. Avoid touching the wound bed, whether with gloves or forceps.

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? a. Desiccation b. Maceration c. Necrosis d. Evisceration

a. Desiccation

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

a. Discontinue the therapy and assess the client.

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

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

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client? a. Monitor intake and output. b. Assess the coccyx area for blanching. c. Monitor the client for nausea. d. Assess mental status.

a. Monitor intake and output.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? a. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown b. Superficial, which may be pinkish or red with no blistering c. May vary from brown or black to cherry red or pearly white; bullae may be present d. A superficial partial-thickness burn, which can appear dry and leathery

a. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

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

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

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? a. transparent film b. hydrocolloid c. hydrogel d. alginate

b. hydrocolloid

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? a. gauze b. transparent c. hydrocolloid d. bandage

b. transparent

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

b. use pillows to maintain a side-lying position as needed

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action? a. Reassure the client that this is a normal effect of a sitz bath and monitor the client closely. b.. Stop the sitz bath, call for help, and help the client to the toilet to sit down. c. Stop the sitz bath and help the client ambulate back to the client room. d. Call a code blue because the client may be experiencing a myocardial infarction.

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

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

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

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

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

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

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

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a. Contact the surgeon for debridement. b. Using sterile technique, debride the wound. c. Off-load pressure from the heel. d. Place an antiembolism stocking on the client's leg.

c. Off-load pressure from the heel.

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

c. elevating and supporting the stump

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? a. avulsion b. abrasion c. incision d. laceration

c. incision

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? a. primary intention b. maturation c. secondary intention d. tertiary intention

c. secondary intention

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? a. serous b. sanguineous c. serosanguineous d. purulent

c. serosanguineous

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? a. Determine the extent of wound undermining. b. Measure length, width, and depth of the wound. c. Massage the healthy tissue surrounding the wound. d. Document the color, odor, amount, and type of wound drainage.

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

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

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

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? a. The nurse uses a safety pin to attach the pad to the bedding. b. The nurse covers the heating pad with a heavy blanket. c. The nurse places the heating pad under the client's neck. d. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

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

True or False: A Penrose drain typically exits a client's skin through a stab wound created by the surgeon

True

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? a. stage I b. stage II c. stage III d. stage IV

b. stage II

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

a. "Very little scar tissue will form."

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

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

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. a client sitting in a chair who slides down b. a client who lifts himself up on his elbows c. a client who lies on wrinkled sheets d. a client who must remain on his back for long periods of time

a. a client sitting in a chair who slides down

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? a. refer the client to a local group which provides home-delivered meals b. encourage the client to spend time at an assisted living facility before returning home c. provide neighbors with proper education to provide care d. inspect the home for potential safety issues

a. refer the client to a local group which provides home-delivered meals

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? a. "Dehiscence is not anything that you need to worry about." b. "Dehiscence is when a wound has partial or total separation of the wound layers." c. "Dehiscence is a total separation of the wound with protrusion of the viscera through it." d. "Dehiscence is the softening of tissue due to excessive moisture."

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

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? a. Stage I b. Stage II c. Stage III d. Stage IV

b. Stage II

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

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

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

d. The status of the client's tetanus immunization

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

d. figure-of-eight turn