Taylor Review Questions - Wounds/Skin Integrity

The nurse and client are looking at a client's heel pressure injury. The client asks "why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

"Necrotic tissue is devitalized tissue that must be removed to promote healing" RATIONALE: The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

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?

"Steri-Strips will hold my wound together until it heals." RATIONALE: After a Cesarean section, a client will be sutured and have staples put in place for a number of days. The healthcare provider or nurse will remove staples. Sterile-strips are not strong enough to hold this type of wound together.

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? SATA

- 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 RATIONALE: The nurse would administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. The medication would be in the client's system at the time of the dressing change. The nurse would change the dressing midway between meals so that pain and discomfort would be at a minimum at the time of the meal. A protective paste or ointment would protect the surrounding skin from the drainage of the wound. There is no need to apply another layer of protective ointment or paste on top of the previous layer when changing dressings. The nurse would not apply an absorbent dressing material as the first layer of the dressing. The nurse wants to wick the drainage from the wound. The nurse would not apply a nonabsorbent material over he first layer of absorbent material. Again, the nurse wants to wick the drainage from the wound.

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order:

- hemostasis - inflammatory - proliferation - maturation

The nurse is using the Braden Scale to determine a client's risk for pressure injuries. What criteria will the nurse assess? SATA

- sensory perception - nutrition - ability - friction

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 critical care client RATIONALE: Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client.

A client's risk for the development of a pressure injury is most likely due to which lab result?

Albumin 2.5 mg/dL RATIONALE: An albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury. A hemoglobin A1C level greater than 8% puts the client at risk for the development of pressure injuries due to a prolonged high glucose level. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not put the client at risk for the development of a pressure injury.

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?

Albumin 2.8 mg/dL RATIONALE: An albumin of less than 3.2 mg/dL increases the risk of the client developing a pressure injury. This indicates that the client is nutritionally deficient. The hemoglobin A1C level of 5% is a normal value. The BUN level is within normal limits. The white blood cell count is also a normal value.

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

An obese woman with a history of type 1 diabetes RATIONALE: Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

Apply the skin barrier at least 1 in away from the area of irritation RATIONALE: The skin barrier should be placed at least 1 in away from the area of irritation and should be placed on both sides of the wound. Skin barrier should not be placed on both sides of the wound. Skin barrier should not be placed over the area of irritation; it should only be placed on skin that is intact. The skin barrier should be applied to both sides of the wound as the Montgomery straps are applied to both sides of the wound on the intact skin surrounding the would and 1 in away from any irritated or nonintact skin.

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?

Braden Scale RATIONALE: The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glascow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

Corticosteroids RATIONALE: Clients 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. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

Document the findings. RATIONALE: The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is not need to contact the heath care provider or the wound care nurse. The nurse should not change the surgical dressing. Most often, the surgeon will change the first dressing in 24-48 hours. For this reason, the wound care nurse does not need to be notified.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as

Milia RATIONALE: Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.

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?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. RATIONALE: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel RATIONALE: The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. The surgeon does not need to be consulted for a debridement. Utilizing an antiembolism stocking on the client will not impact the status of the heel would.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?

Reduce the time interval between dressing changes. RATIONALE: Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing is not indicated.

Which best describes the proliferative phase, the third phase of the wound healing process?

Reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization. RATIONALE: In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing, hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?

Supports the area around the wound RATIONALE: Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wrapped on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle and wrist.

The nurse is preparing to inset an IV for a client with dehydration. Which dressing supply will the nurse father to take in the client's room?

Tegaderm RATIONALE: 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 keep a wound moist.

A client has been admitted to the acute care unit after surgery to debridement an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?

Tertiary intention RATIONALE: Healing by tertiary intention occurs when a delay ensues between injury and wound closure. This type of healing also is referred to as delayed primary closure. It may happen when a deep wound is not sutured immediately or is purposely left open until there is no sign of infection, then closed with sutures. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the primary wound are approximated or lightly pulled together. Wounds with full-thickness tissue loss, such as deep lacerations, burns and pressure injuries, have edges that do not readily approximate. They heal by secondary intention. The open wound gradually fills with granulation tissue.

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

The client has fistula formation RATIONALE: A fistula is an abnormal tubelike passageway that forms from one organ to outside the body. There is not information that would lead to a suspicion that the wound is infected. Wound dehiscence would be indicated by separation of the wound and evisceration would be evidenced by protrusion of abdominal contents through the wound.

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. RATIONALE: Sometimes the physician orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain dose not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. RATIONALE: A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.

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. RATIONALE: 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 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 teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is:

To provide drainage for bile RATIONALE: A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. He oval and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

A health care provider orders irrigation with normal saline for the treatment of a client's wound. what should the nurse do when performing this intervention?

Use clean technique instead of sterile technique if the wound is closed.

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "yellow". Based on this classification, which nursing action should the nurse perform?

Wound irrigation RATIONALE: With the yellow classification using the RYB would classification system, would irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present.