PrepU Chapter 32: Skin Integrity and Wound Care

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?

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

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?

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

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

A. "Do you experience incontinence?" B. "Do you use any lotions on your skin?" C. "How many meals a day do you eat?" D. "Have you had any recent illnesses?" A

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?

A. "That is called undermining, a type of tissue erosion." B. "That is necrotic tissue, which must be removed to promote healing." C. "That is old clotted blood underneath the wound" D. "This is normal tissue." B

A client with the history of systemic lupus erythematosus underwent a surgical repair of a right inguinal hernia. The client now presents to the emergency department with the report that the incision appears to have opened. Which action should the nurse prioritize after performing the focused assessment?

A. question the use of prednisone B. request a stronger pain medication C. collect drainage from skin for culture and sensitivity testing D. administer ibuprofen for pain A

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 II B. stage I C. stage III D. stage IV A

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

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

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. Maceration B. Necrosis C. Evisceration D. Desiccation D

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?

A. Green beans B. Fish C. Pasta salad D. Banana B

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

A. A client who is NPO (nothing by mouth) following bowel surgery B. a client whose breast reconstruction surgery required numerous incisions C. an obese woman with a history of type 1 diabetes D. a man with a sedentary lifestyle and a long history of cigarette smoking C

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. An individual's skin changes little over the life span. C. A child's skin becomes less resistant to injury and infection as the child grows. D. In children younger than 2 years, the skin is thicker and stronger than in adults. A

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

A. Clean the wound in a circular pattern, beginning on the perimeter of the wound. B. Use clean technique to clean the wound. C. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. D. Clean the wound from the top to the bottom and from the center to outside. D

Which would be appropriate action(s) for the nurse to take when cleaning and dressing a pressure injury? Select all that apply.

A. Clean the wound with each dressing change using aggressive motions to remove necrotic tissue. B. Use whirlpool treatments, if prescribed, until the injury is considered clean. C. Use a dressing that absorbs exudate but maintains a moist healing environment. D. Pack wound cavities densely with dressing material to promote tissue healing. E.Keep the injury tissue moist and the surrounding skin dry. F. Use povidone-iodine or hydrogen peroxide to irrigate and clean the injury. B, E, C

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

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.

A. Fingers with quick capillary refill B. Decreased radial pulse C. No finger numbness or tingling D. Cyanosis E. Warm hand A, C, E

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 who must remain on the back for long periods of time B. a client sitting in a chair who slides down C. a client who lies on wrinkled sheets D. a client who lifts himself up on the elbows B

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. a critical care client B. an older client with arthritis C. a client with cardiovascular disease D. a newborn A

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. assessing for impaired blood flow to the area of evisceration. C. applying sterile dressings with normal saline over the protruding organs and tissue D. monitoring for pallor and mottled appearance of the wound C

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

A. dehiscence. B. infection. C. herniation. D. evisceration. A

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. Do not attempt to remove the sutures because the wound needs more time to heal. 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. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. D

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?

A. Herniation of the wound B. Infection of the wound C. Evisceration of the viscera D. Dehiscence of the wound D