Tissue integrity

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

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

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?

"Reinforced adhesive skin closures will hold my wound together until It heals"

A client is schedule for an exam and pap procedure, what teaching should the nurse provide about douching?

"do not douche for 24-48 hours before the procedure"

The nurse is teaching a client about healing of minor surgical wound by first intention teaching will the nurse include?

"very little scare tissue will form"

A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply.

-"It may take longer for an older adult to heal." -"Consider having a home health aide to assist with bathing and personal care." -"Older adults with lots of sun exposure may experience delayed healing."

The nurse is providing care to a postoperative client who has a Jackson-Pratt (JP) drain. The nurse notes that the JP drain is expanded and full of sanguineous fluid. Place in order the steps the nurse will perform/

-Don clean gloves -Empty the JP contents into graduated collect container -Compress the chamber and replace the JP cap -Note the amount of output, as well as its color -Remove gloves and sanitize or wash hands

The client cut his leg on a gardening tool several days ago and is being seen for an infected wound. The nurse is going to obtain a culture of the wound and then re-dress the wound. What are the steps, in order, for the nurse to obtain the wound culture and re-dress the wound? Arrange the following steps in the correct order.

-Remove the soiled dressing wearing clean gloves. -Clean the wound, wearing sterile gloves and using sterile supplies. -Dry the surrounding tissue with gauze. -Insert the culture swab deep into the wound, wearing clean gloves. -Using a different pair of gloves, place a clean dressing on the wound.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

A Penrose drain promotes passive drainage into a dressing

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client is most likely to develop a pressure injury from shearing?

A client sitting in a chair who slides down

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

A student fell on both knees while running and the knees have turned shades of blue and purple? Which type of injury does the nurse anticipate assessing?

Contusion (bruise)

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 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?

Elevating and supporting the stump

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

Evisceration

The nurse is helping a confused client with a large leg wound order dinner. Which is appropriate for the nurse to select to promote wound healing?

Fish High protein and Vitamins. C and A for wound healing

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?

Gauze

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

A client birthed twins via cesarean and is learning to care for incision. Which teaching will the nurse include?

It is important to keep your sutured incision clean

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factor. Which is not these factors?

Local capillary pressure must be lower than external pressure

A nurse removing suture from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crust before removing sutures

Which activity should the nurse implement to decrease shearing force on a client's stage 2 pressure injury?

Prevent the client from sliding in bed

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

Primary intention

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

Secondary intention

During a dressing change of a surgical site the nurse observed a water pink drainage. What type of drainage should the nurse document

Serosanguineous

The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care?

Soaking in a warm bath for drainage

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 3

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making?

The nurse should apply adhesive wound closure strips after removing staples

A client who was injured when stepping on a rested nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

The nurse is caring for a client with a knee sprain. What guidelines will the nurse teach the client about using an ice pack at home?

There should be a cloth barrier around the ice pack for each 20-min therapy

A health care provider order irrigation with normal saline for treatment of a clients wound. What should the nurse do when performing this intervention?

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

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?

assessing wound for active bleeding

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

corticosteroids

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?Depth

depth

A skin infection caused by beta-hemolytic streptococci common in children is

impetigo

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

nurse jeep pad in place for 20-30 min assessing regularly

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

A Penrose drain typically exists a clients skin through a stab wound created by the surgeon

true