Therapeutics - Chapter 32: Skin Integrity and Wound Care

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?"

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 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 must wait 15 minutes between applications of cold therapy."

"I will put a layer of cloth between my skin and the ice pack."

The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"It provides a way to remove drainage and blood from the surgical wound."

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles. Use an aquathermia pad during the treatment to create heat and circulate the water.

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For which type(s) of injury would the nurse be alert?

Broken left ankle Abrasions Soft tissue damage Concussion Bruising

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the 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?

Dehiscence of the wound

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? Document the findings in the client's medical record. Notify the health care provider of the findings. Discontinue the therapy and assess the client. Gently rub and massage the area to warm it up.

Discontinue the therapy and assess the client.

The nurse is performing frequent skin assessments at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

Discontinue the therapy and assess the client.

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?

Impaired tissue integrity

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

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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.

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? Hemovac drain Jackson-Pratt drain Wound pouching Penrose drain

Penrose drain

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

an obese woman with a history of type 1 diabetes

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

apply saline solution-moistened gauze over the protruding area.

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?

contusion

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

eschar.

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell foul-smelling drainage that is grayish in color small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color

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