Skin Integrity and Wounds

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate? A. evisceration B. infection C. dehiscence D. fistula

B

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? A. Glascow scale B. Braden scale C. FLACC scale D. Morse scale

B

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

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. "This drain minimizes the chance for bacteria to enter the surgical site." 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

A nurse is caring for a client who has a 6 × 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 most likely to be ordered by the primary care provider? A. alginate B. hydrogel C. hydrocolloid D. transparent

A

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. contusion B. incision C. avulsion D. puncture

A

The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, the nurse will incorporate which nursing measure? A. Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. B. Plan to administer a prescribed analgesic immediately prior to the dressing change. C. Perform the dressing change when the client is fatigued after physical therapy. D. Perform the dressing change during mealtime to allow for distraction.

A

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and unblanchable. How will the nurse categorize this pressure injury? A. stage I B. stage II C. stage III D. stage IV

A

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select? A. Hydrocolloid B. Wet to dry C. Negative wound pressure therapy D.Telfa

A

A full-thickness or third-degree burn develops a leathery covering called a(an): A. eschar. B. static. C. abrasion. D. erythema.

A

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? A. removing dead or infected tissue to promote wound healing B. stimulating the wound bed to promote the growth of granulation tissue C. removing purulent drainage from the wound bed in order to accurately assess it D. removing excess drainage and wet tissue to prevent maceration of surrounding skin

A

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and: A. covering the wound area with sterile towels moistened with sterile 0.9% saline. B. closing the wound area with reinforced adhesive skin closures. C. pouring sterile hydrogen peroxide into the abdominal cavity and packing it with gauze. D. holding the wound together until the health care provider arrives.

A

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them? A. Apply moist saline compresses to loosen crusts before attempting to remove the staples. B. Go ahead and remove the staples as they will pop up and out of the skin. C. Notify the health care provider of the dried blood and wait for a prescription to proceed. D. Apply a warm compress to the surgical staples and allow the dried blood to melt.

A

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 action by the nurse is appropriate in this situation? Select all that apply. A. covering the wound with a gauze moistened with normal saline B. reinserting the protruding structures and applying a pressure dressing C. placing the client in the low Fowler position D. using sterile technique E. packing the wound with iodoform gauze

A, C, D

A client comes to the emergency department after falling off a skateboard onto the sidewalk. Which assessment data, consistent with an abrasion, would the nurse expect to see? A. clean separation of skin and tissue with even edges B. scraping off of surface layers of skin C. stripping away of large area of skin and tissue, with exposed bone D. opening of skin and underlying tissue caused by a sharp, pointed object

B

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to? A. bowel obstruction B. decubitus ulcer C. depression D. urinary incontinence

B

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 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