Skin Integrity and Wound Care: Chapter 31

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) "The surgeon will leave your wound intentionally open for a period of time." C) "This is a complex reparative process." D) "The margins of your wound are not in direct contact."

A) "Very little scar tissue will form."

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

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood? A) Gauze B) Tegasorb C) Duoderm D) OpSite

A) Gauze

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

A) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

A client with anorexia nervosa has developed a pressure wound on the sacrum. What laboratory results would indicate the client is at nutritional risk? A) Total lymphocyte count of 1,500/mm3 B) Arm muscle circumference 90% of standard C) Body weight decrease of 3% D) Albumin level of 3.5 mg/dL

A) Total lymphocyte count of 1,500/mm3

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

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

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure ulcer? A) Use pillows to maintain a side-lying position as needed. B) Elevate the head of the bed 90 degrees. C) Provide incontinent care every 4 hours as needed. D) Place a foot board on the bed.

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

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces? A) 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 would recognize which client as being particularly susceptible to impaired wound healing? A) an obese woman with a history of type 1 diabetes B) A client who is n.p.o. (nothing by mouth) following bowel surgery C) a client whose breast reconstruction surgery required numerous incisions D) a man with a sedentary lifestyle and a long history of cigarette smoking

A) an obese woman with a history of type 1 diabetes

A skin infection caused by beta-hemolytic streptococci common in children is: A) impetigo. B) herpes. C) scabies. D) acne vulgaris.

A) impetigo

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? A) shearing force B) friction C) necrosis of tissue D) ischemia

A) shearing force

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

B) "Do you experience incontinence?"

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching? A) "I may have staples in place for a number of days." B) "Steri-Strips will hold my wound together until it heals." C) "I will not remove the staples myself." D) "After delivery, I will have sutures in place."

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

The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate? A) "Allowing a scab to form would prevent us from observing the wound for signs of infection." B) "Wounds heal better when a moist wound bed is maintained." C) "You may be correct. I will check with your primary health care provider." D) "This wound is too large for a scab to form over it, so a moist dressing is the best alternative."

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

A nurse is caring for a client who has a 6-cm × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which dressing does the nurse anticipate is best to be ordered by the primary care provider? A) Hydrogel B) Alginate C) Transparent D) Hydrocolloid

B) Alginate

Which is not considered a skin appendage? A) Eccrine sweat glands B) Connective tissue C) Hair D) Sebaceous gland

B) Connective tissue

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? A) Necrosis B) Desiccation C) Evisceration D) Maceration

B) Desiccation

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse to select to promote wound healing? A) Green beans B) Fish C) Banana D) Pasta salad

B) Fish

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

B) Stage III

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer? A) Improve the client's hydration. B) Support the client from sliding in bed. C) Pull client up under the arms. D) Lubricate the area with skin oil.

B) Support the client from sliding in bed.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? A) incision B) contusion C) avulsion D) puncture

B) contusion

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 can let this stay on my ankle an hour at a time." B) "I should keep this on my ankle until it is numb." C) "I will put a layer of cloth between my skin and the ice pack." D) "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."

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include? A) "Steri-Strips can be peeled off after 48 hours." B) "You only need a binder to hold your incision together." C) "It is important to keep your sutured incision clean." D) "You will have staples in place for several weeks."

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

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? A) An individual's skin changes little over the life span. B) An infant's skin and mucous membranes are easily injured and at risk for infection. 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.

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

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention? A) Assess for impaired blood flow to the area of evisceration. B) Monitor for pallor and mottle appearance of the wound. C) Apply sterile dressings with normal saline over the protruding organs and tissue. D) Contact the surgeon.

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

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? A) Stage IV B) Stage III C) Stage II D) Stage I

C) Stage II

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition? A) The edges of the wound are lightly pulled together. B) There is an accumulation of fluid in the interstitial tissue. C) There is an unintentional separation of the wound. D) There is redness or inflammation of an area as a result of dilation.

C) There is an unintentional separation of the wound.

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

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

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

C) a sterile, flexible applicator moistened with saline

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely: A) fourth degree or fat layer B) third degree or full thickness C) second degree or partial thickness D) first degree or superficial

C) second degree or partial thickness

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? A) "Dehiscence is the softening of tissue due to excessive moisture." B) "Dehiscence is not anything that you need to worry about." C) "Dehiscence is a total separation of the wound with protrusion of the viscera through it." D) "Dehiscence is when a wound has partial or total separation of the wound layers."

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

The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment? A) "The Pap procedure includes application of a douche." B) "Douching is recommended so that you are clean for the examination." C) "Plan to begin douching routinely immediately after your procedure." D) "Do not douche 24-48 hours before the procedure."

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

The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? A) Assess the client's mental status. B) Assess the client for claustrophobia. C) Assess for the use of antihypertensives. D) Assess the wound for active bleeding.

D) Assess the wound for active bleeding.

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? A) Once the wound is cleaned, dry the area with an absorbent cloth. B) Clean the wound from the bottom to the top, and outside to center. C) Use clean technique to clean the wound. D) Clean the wound from the top to the bottom, and center to outside.

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

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) Infection of the wound B) Evisceration of the viscera C) Herniation of the wound D) Dehiscence of the wound

D) Dehiscence of the wound

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which of the following actions should the nurse perform in obtaining a wound culture? 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 inside of the culture tube sterile.

D) Keep the swab and inside of the culture tube sterile.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? A) Pick the crusts off the sutures with the forceps before removing them. B) Do not attempt to remove the sutures because they need more time to heal. C) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. D) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

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

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) Hydrocolloid C) Bandage D) Transparent

D) Transparent

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A) a wound healing naturally that becomes infected. B) a wound left open for several days to allow edema to subside C) a large wound with considerable tissue loss allowed to heal naturally D) a surgical incision with sutured approximated edges

D) a surgical incision with sutured approximated edges

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

True