Skin Integrity
The nurse is preparing to measure the depth of a client's tunneled wound. Which of the following implements should the nurse use to measure the depth accurately?
A sterible flexible applicator moistened with saline
The nurse is assessing the wounds of patients in a burn unit. Which wound would most likely heal by primary intention?
A surgical incision with sutured approximated edges.
Then nurse would recognize which of the following clients as being particularly suseptable to impaired wound healing
An obese woman with a history of type 1 diabetes
A nurse is caring for a client who has a pressure ulcer on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-blue (RYB) Wound Classification System, which of the following classifications should the nurse document?
Black Classification
A nurse is cleaning the wound of a gunshot victim. Which of the following is recommended guideline for this procedure?
Clean the wound from top to bottom and center to outside.
Upon review of a postoperative patient's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
Corticosteroids Patients 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
A nurse is caring for a client on a medical surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which of the following actions by the nurse are appropriate in this situation? Select all that apply.
Cover wound with gauze place supine postion Use sterile techniques
Which of the following actions should the nurse perform when applying negative pressure wound therapy?
Cut foam to the shape of the wound and place it in the wound.
A client is suffering from infectioius diarrhea, dehydration and right sided paralysis is confined to bed. What is the client most prone to?
Decubitus Ulcer
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?
Dehiscence of the wound 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 physician. 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
A med surg nurse is assessing woulds of patients. Which wound coplications accurately described below?
Dehiscience- patrtial or total disruption of wound layers Evisertation Postoperative fistulas
The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?
Desiccation 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
The nurse is changing a dressing of a patient with a gunshot wound. What nursing action would the nurse provide?
Dressing that absorbs exudate, but maintains moist environment.
A nurse is assessing patient wounds would document which examples as healing normally?
Edges h ealing, with crust wound that doesnt feel hot forms excudate
The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing?
Fish- Fish is high in protein to promote protein
The nurse is assessing the wounds of patients. Which patients would be at most risk for delayed would healing.?
Older patient who is bed ridden patient with peripheral vascular disorder a patient who is obese a patient who is taking cortcosteriod drugs
A nurse is assessing the wound healing of a patient, documents that the wound formed a clean, straight line with little tissue loss. This would healed by:
Primary Intention
A nurse assesses an area of pale white skin over a patient's coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?
Recognize that this is ischemia, followed by reactive hyperemia. Explanation: Blanching of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
Removing dead or infected tissue to promote wound healing
Stages of a wound
Stage I- inact skin with non blanchable redness Stage II- partial tissue loss such as a blister Stage III- wound with full thickness tissue loss. Stage IV- full tissue loss with exposed bone, tendon, or muscle.
A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which of the following stages should the nurse assign to this client's wound?
Stage III
A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which of the following stages should the nurse document for this wound?
Suspected deep tissure ingury. A marroon filled bilstered is often boggy or painful area.
The nurse is caring for a penrose drain. What nursing action reflects a step to care for the penrose drain that needs to be shortened everyday.
The nurse pulls the drain out a short distance using sterile scissors and a twisting motion and cuts off the end of the drain with sterile scissors.
A nurse is preparing to file a safety event report after a client experienced a fall. The nurse is aware that which statement below is correct regarding the filing of a safety event report?
The nurse should record the incident in the client's medical record and fill out a safety event report separately.
The nurse is caring for a patient who has a pressure ulcer on his back. What nursing intervention would the nurse perform?
The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair
The nurse caring for a postoperative patient is cleaning the patients wound. Which nursing action reflects the proper procedure?
The nurse works outward from the wound in lines parallel to it.
A student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as unstageable. Which of the following wound descriptions should the student nurse expect to assess?
The wound is 3cm x 5cm with yellow tissue covering the entire wound
A female patient who is being treated for self inflicted wounds tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk?
Total lymphocyte count of 1,500/mm3
While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record?
Unintentional, partial-thickness wound. Explanation: An unintentional wound is an accidental wound. A partial-thickness wound is characterized by all or a portion of the dermis remaining intact
The nurse s giving a back rub to a patient and notices a stage 2 pressure ulcer. What should the nurse do next?
Use normal saline to clean the pressure ulcer
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 of the following actions should the nurse perform to prevent a pressure ulcer?
Use pillows to maintain a side lying postion as needed
You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate?
Wounds heal better when a moist wound bed is maintained." Explanation: A moist wound surface enhances the cellular migration necessary for tissue repair and healing.
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 of the following responses by the nurse is most appropriate?
Your wound will heal slowly as granulation tissue forms and fills the wound.
The nurse is assessing the wounds of patients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges.
The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?
dehiscence is when a would has partial or total seperation of the wound layers
Secondary Intention
large wounds with considerable tissue loss
You are preparing to irrigate a patient's wound. Arrange the following steps in the correct order.
mask gown eyes take off soiled sterile gloves fill syringe direct stream dry area
In which situations has the nurse used a dressing properly?
opsite aseptic techniqes sof wick
Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a patient's wound? (Select all that apply.)
• Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. • Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. • Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end.
