Skin Integrity and Wound Care PREPU

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 I Stage II Stage III Stage IV

stage II

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? Gauze Transparent Hydrocolloid Bandage

Transparent

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? "You will receive medication through this device." "This drain minimizes the chance for bacteria to enter the surgical site." "It provides a way to remove drainage and blood from the surgical wound." "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."

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? Local capillary pressure must be lower than external pressure. The heart must be able to pump adequately. The volume of circulating blood must be sufficient. Arteries and veins must be patent and functioning well.

Local capillary pressure must be lower than external pressure.

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? Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Pick the crusts off the sutures with the forceps before removing them. Do not attempt to remove the sutures because they need more time to heal.

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

The nurse observes the client for signs of stage I pressure injury development, which is most likely to include which finding? nonblanchable redness a shallow, open injury visible subcutaneous fat exposed bone with eschar

Nonblanchable Redness

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

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

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

"Do you experience incontinence?"

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? "Do not douche 24-48 hours before the procedure." "Douching is recommended so that you are clean for the examination." "Plan to begin douching routinely immediately after your procedure." "The Pap procedure includes application of a douche."

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

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? "Wounds heal better when a moist wound bed is maintained." "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." "You may be correct. I will check with your primary health care provider." "Allowing a scab to form would prevent us from observing the wound for signs of infection."

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

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

The nurse is discussing home remedies for insect bites with a group of college students. The nurse correctly includes which remedy in the presentation? Chamomile Lavendar Aloe vera Tree tea oil

Aloe Vera

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

Assess the wound for active bleeding

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

Dehiscence

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 Herniation of the wound Dehiscence of the wound Evisceration of the viscera

Dehiscence of the wound

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? Size Depth Tunneling Direction

Depth

A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse? Discard the swab and inform the health care provider that the wound is too infected to culture Obtain the swab as prescribed and send it to the lab for culture Obtain the swab and then clean the wound Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab

Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab

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? Pasta salad Fish Banana Green beans

Fish

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

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

Which is not a protective function of the skin? Sebum gives the skin an acidic pH, which retards the growth of microorganisms. Keratin protects against the sun's ultraviolet rays. Microorganisms that inhibit the growth of pathogens are present on the skin. It contains cells such as macrophages that protect it.

Keratin protects against the sun's ultraviolet rays.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage?

Serosanguineous

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? friction necrosis of tissue ischemia shearing force

Shearing force

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? Epidermis Dermis Subcutaneous tissue Muscle layer

Subcutaneous Tissue

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

Tearing of a structure from its normal position

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? gauze Montgomery straps Tegaderm DuoDerm

Tegaderm Transparent dressings like Tegaderm are used to protect intravenous insertion sites. Montgomery straps are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings like DuoDerm are used to used keep a wound moist.

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 selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. 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. ((Wounds are to be packed loosely))

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

True

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? Elevate the head of the bed 90 degrees. Use pillows to maintain a side-lying position as needed. Provide incontinent care every 4 hours as needed. Place a foot board on the bed.

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

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

a client sitting in a chair who slides down

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

What is the most accurate definition of a wound? a disruption in normal skin and tissue integrity a change in the function of internal organs any injury that results in changes in nervous tissue any trauma resulting in serious damage and pain

a disruption in normal skin and tissue integrity

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

a surgical incision with sutured approximated edges

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 in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? a transparent film a gauze dressing precut halfway to fit around the IV line a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics

a transparent film

The nurse would recognize which client as being particularly susceptible to impaired wound healing? an obese woman with a history of type 1 diabetes a client whose breast reconstruction surgery required numerous incisions a man with a sedentary lifestyle and a long history of cigarette smoking A client who is n.p.o. (nothing by mouth) following bowel surgery

an obese woman with a history of type 1 diabetes

The nurse is performing an admission assessment on a client being admitted to a long-term care facility. The nurse notes the client has a history of psoriasis. Which locations on the body is the nurse most likely to find manifestations consistent with the condition? Select all that apply. Trunk Elbows Knees Soles of the feet Neck

elbows knees soles of the feet

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

figure-of-eight turn A figure-of-eight turn is used for joints like elbows and knees. Other answers are incorrect. circular turn = ankle

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? avulsion abrasion incision laceration

incision

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 stimulating the wound bed to promote the growth of granulation tissue removing purulent drainage from the wound bed in order to accurately assess it removing excess drainage and wet tissue to prevent maceration of surrounding skin

removing dead or infected tissue to promote wound healing

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: first degree or superficial second degree or partial thickness third degree or full thickness fourth degree or fat layer

second degree or partial thickness

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

very little scar tissue will form

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

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

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 should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy." "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 will put a layer of cloth between my skin and the ice pack."

A nurse is assessing a pressure injury 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? Stage I Stage II Stage III Stage IV

Stage III

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

Connective Tissue

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? Exert equal, but not excessive, tension with each turn of the bandage. Wrap distally to proximally. Elevate and support the stump. Keep bandage free from gaps between each turn.

Elevate and support the stump. 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.

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 uses friction when cleaning the wound to loosen dead cells. 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 works outward from the wound in lines parallel to it. 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.

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

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

A client with a history of pressure injuries is discussing nutrition with the nurse. The client correctly indicates plans to include which vitamin in the diet to promote wound healing? Select all that apply. Vitamin D Vitamin B3 (niacin) Vitamin B6 (pyridoxine) Vitamin B7 (biotin) Vitamin B9 (folic acid)

Vitamin B3 (niacin) Vitamin B6 (pyridoxine)

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? transparent films hydrocolloid dressings hydrogels alginates

hydrocolloid dressings 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.

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? OpSite Gauze Tegasorb Duoderm

Gauze

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? "I may have staples in place for a number of days." "I will not remove the staples myself." "After delivery, I will have sutures in place." "Steri-Strips will hold my wound together until it heals."

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

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply. Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. Change the dressing midway between meals. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. Apply an absorbent dressing material as the first layer of the dressing. Apply a nonabsorbent material over the first layer of absorbent material.

Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. Change the dressing midway between meals. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound.