TLB-Chapter 32: Skin Integrity and Wound Care

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: an allergic reaction to medications. an allergic reaction to detergent. a rash related to a yeast infection. a rash related to immobility.

a rash related to a yeast infection. Explanation: Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.

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 Explanation: The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "This is normal tissue." "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing."

"That is necrotic tissue, which must be removed to promote healing." Explanation: Wounds that are brown or black are necrotic and not considered normal. 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 has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? Apply a skin protectant to the skin around the incision. Apply a skin protectant to the incision site. Apply a sterile gauze sponge over the incision site. Apply a transparent dressing over the incision site.

Apply a skin protectant to the skin around the incision. Explanation: Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? Assess the client's wound and vital signs. Administer the prescribed analgesic. Notify the health care provider of the pain. Document the pain and vital signs.

Assess the client's wound and vital signs. Explanation: First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

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? Glascow scale Braden scale FLACC scale Morse scale

Braden scale Explanation: 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

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Desiccation Maceration Necrosis Evisceration

Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

A nurse is providing wound care for a client who has a pressure inury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Give pain medication. 2Use nonsterile gloves. 3Remove old dressing. 4Apply sterile gloves. 5Cleanse the wound with normal saline. 6Apply wound covering.

Give pain medication. Use nonsterile gloves. Remove old dressing. Apply sterile gloves. Cleanse the wound with normal saline. Apply wound covering. Explanation: The correct order for this dressing change is giving pain medication, applying nonsterile gloves to remove old dressing, removing old dressing, applying sterile gloves, cleansing the wound with normal saline, and applying a wound covering.

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? Hydrocolloid Wet to dry Negative wound pressure therapy Telfa

Hydrocolloid Explanation: The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement. Telfa pads are nonstick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement. Reference:

When applying an external heating pad, which prescription from the health care provider would the nurse question? Leave heating pad on for 40 to 45 minutes, then off for 2 hours. Assess site frequently during application of the heating pad. Use gauze to secure the heating pad to the site of application. Maintain the temperature between 105°F to 109°F (40.5°C to 43°C).

Leave heating pad on for 40 to 45 minutes, then off for 2 hours. Explanation: The nurse should question the prescription to leave the heating pad on for 40 to 45 minutes, because this is too long and could cause a rebound phenomenon. Using heat for more than 20 to 30 minutes can result in tissue congestion, vasoconstriction, and increases the risk of tissue damage. All other prescriptions are recommended guidelines for use of a heating pad.

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client? Monitor intake and output. Assess the coccyx area for blanching. Monitor the client for nausea. Assess mental status.

Monitor intake and output. Explanation: A client with diarrhea caused by Clostridium difficile is at risk for dehydration. As such, the priority assessments should include intake and output, skin turgor, condition of mucous membranes, and vital signs. Assessing the coccyx area for blanching should be done with shift assessments; however, circulating fluid volume takes priority. Monitoring for nausea and assessing the client's mentation is not directly related to the effects of the infectious diarrhea.

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple is removed. Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision.

Stop removing staples and inform the surgeon Explanation: If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.

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 Maintains a moist environment Keeps the wound clean Reduces swelling and inflammation

Supports the area around the wound Explanation: 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.

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? Gentle cleansing Wound irrigation Debridement Apply moist dressing

Wound irrigation Explanation: With the yellow classification using the RYB wound classification system, wound 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.

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatestrisk 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 Explanation: 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 recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon applying sterile dressings with normal saline over the protruding organs and tissue assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound

applying sterile dressings with normal saline over the protruding organs and tissue Explanation: The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? autolytic debridement biosurgical debridement enzymatic debridement mechanical debridement

biosurgical debridement Explanation: In biosurgical debridement, fly larvae are used to clear the wound of necrotic tissue. This is accomplished by an enzyme the larvae releases. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, as in surgical debridement.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? corticosteroids antihypertensive drugs potassium supplements laxatives

corticosteroids Explanation: 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.

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

dehiscence. Explanation: Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

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? fistula dehiscence hemorrhage evisceration

evisceration Explanation: Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: milia. prickly heat. acne vulgaris. lanugo.

milia. Explanation: 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.

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 Explanation: Partial-thickness burns may be superficial or moderate to deep. A superficial partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good example. Moderate to deep partial-thickness burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present. The full-thickness burn appears dry and leathery.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? stage I stage II stage III stage IV

stage IV Explanation: Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

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 adhesive strips with eyelets transparent hydrocolloid

transparent Explanation: Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist.

The nurse is caring for a client who has recently noted abnormal pigmentation in his skin. What is most likely deficient in the client's diet? Vitamin A Vitamin B12 Zinc Magnesium

Zinc Explanation: Adequate intake of iron, copper, and zinc is important to prevent abnormal pigmentation and changes in nails and hair. REMEMBER: "ZINC PINK"

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? Notify the surgeon STAT Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Explanation: With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration. Approximating the wound edges and applying wound closure tapes may cause the client undue pain and trap bacteria in the wound. Irrigating the open wound may cause unwanted bacteria from the surrounding area to wash into 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? exerting equal, but not excessive, tension with each turn of the bandage wrapping distally to proximally elevating and supporting the stump keeping the bandage free of gaps between turn

elevating and supporting the stump Explanation: 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.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care? cleanse the wound from the outer area toward the inner area cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing cleanse the wound in parallel strokes from the top to the bottom of the wound cleanse with a new gauze for each stroke

cleanse with a new gauze for each stroke Explanation: When cleansing a wound, the nurse should use a new gauze or swab on each downward stroke of the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside.

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? transparent film hydrocolloid dressing hydrogel alginate

hydrocolloid dressing Explanation: 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.

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 Explanation: An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture. Reference:

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? "This is normal tissue." "That is called slough, and it will usually fall off." "You are seeing undermining, a type of tissue erosion." "Necrotic tissue is devitalized tissue that must be removed to promote healing."

"Necrotic tissue is devitalized tissue that must be removed to promote healing." Explanation: 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.

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? Select all that apply. Broken left ankle Abrasions Soft tissue damage Concussion Bruising Dehydration

Broken left ankle Abrasions Soft tissue damage Concussion Bruising Explanation: Skateboard related injuries that the nurse needs to assess for are a concussion and other brain injuries, broken bones, soft tissue injuries, and skin abrasions, cuts, and bruises. Symptoms of a concussion are dizziness, headaches, visual changes, loss of memory, slowed speech, and sensitivity to noise. An abrasion involves stripping of layers on the skin's surface. Soft tissue injuries include damage to the muscles, tendons, and ligaments. Dehydration can cause headaches and dizziness; however, since the client injured oneself while skateboarding a concussion should be suspected and assessed for. Because the client reported sliding on the sidewalk, the client should also be assessed for skin abrasions.

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings? Diffuse dermatitis accompanied by pruritus Superficial contusion accompanied by pruritus Diffuse fungal infection accompanied by pruritus Superficial abscess accompanied by pruritus

Diffuse dermatitis accompanied by pruritus Explanation: The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching. A contusion is a closed wound with bleeding in underlying tissues from a blunt blow. Fungal infections do not cause a rash or itching. An abscess is a localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed.

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. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Hemostasis 2Inflammatory 3Proliferation 4Maturation

Hemostasis Inflammatory Proliferation Maturation Explanation: The correct order of the phases of wound healing is hemostasis, inflammatory, proliferation, and maturation.

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 mostappropriate? Reduce the time interval between dressing changes. Assure that the packing material is completely saturated when placed in the wound. Use less packing material. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.

Reduce the time interval between dressing changes. Explanation: 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 in not indicated.

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action? Reassure the client that this is a normal effect of a sitz bath and monitor the client closely. Stop the sitz bath, call for help, and help the client to the toilet to sit down. Stop the sitz bath and help the client ambulate back to the client room. Call a code blue because the client may be experiencing a myocardial infarction.

Stop the sitz bath, call for help, and help the client to the toilet to sit down. Explanation: If the client complains of feeling light-headed or dizzy during a sitz bath: Stop the sitz bath. Do not attempt to ambulate the client alone. Use call light to summon help. Let the client sit on the toilet until feeling subsides or help has arrived to assist the client back to bed. This does not necessarily warrant a code blue unless the nurse suspects an acute onset of a serious health problem.

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? "Be sure to take at least two showers daily to remove all microorganisms from the skin." "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." Explanation: Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue. As such, clients should be taught to avoid soaps with artificial ingredients or fragrances, as these may be harsher on the skin. It is good to be clean; however, advice of taking at least two showers per day is excessive and may dry the skin. Moisturizer should be applied to the skin following bathing to prevent dryness of the skin. Drinking water is important to remain hydrated; however, the nurse should recommend drinking 1,500 to 2,000 mL of water daily. Drinking 8 ounces three times a day is 720 mL.

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?" Explanation: The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

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." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.

The nurse is caring for an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help detect the potential for pressure injury? Select all that apply. Stages of pressure injuries Nutritional status Mental status Skin moisture Sensory perception

.ect response: Nutritional status Mental status Skin moisture Sensory perception Explanation: The client has blood clots that could potentially travel to the lungs (thromboembolism), so the client needs to be on strict bed rest until treated for the condition and determined safe to ambulate. Stages of pressure injuries are used after there is a break in the skin's integrity, and the nurse is examining the client for potential risks for developing a pressure injury in this case. Nutritional status is important to assess to determine if skin has adequate nutrients to replace damaged or dead cells daily. In older adults, the first clue of an infection—fluid and electrolyte imbalance—is often a change in the mental status, and all these factors can influence the client not adequately moving in bed and increase pressure on the bony prominences. Skin moisture needs to be assessed because excessively dry or moist skin will break down easier than skin with a normal amount of moisture. Sensory perception is important to assess because if the client cannot feel light touch or painful stimuli, the client may not recognize lying in one position too long, which leads to increased pressure on tissues and damage to the skin

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Avoid using irrigation to clean the wound before changing the dressing. Apply dry gauze to the wound and carefully apply saline to saturate it. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. Explanation: Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

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

Connective tissue Explanation: Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.

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? Contact the health care provider. Change the dressing. Document the findings. Notify the wound care nurse.

Document the findings. Explanation: The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is no need to contact the health 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 to 48 hours. For this reason, the wound care nurse does not need to be notified. Reference:

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen? Impaired Skin Integrity related to open wound Pain related to wound sustained by knife Knowledge Deficit regarding wound care related to laceration Risk for Infection related to wound

Impaired Skin Integrity related to open wound Explanation: Impaired skin integrity best describes the minor laceration. While the other diagnoses, Pain, Knowledge Deficit, and Risk for Infection, are all possible as a result of the laceration, there is no indication in the scenario that they are the case.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done. Use the same swab for both wound sites. Touch the swab to the intact skin at the wound edges. Tap the outside of the culture tube with the swab before placing it in the tube.

Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done. Explanation: The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination. Reference:

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. Explanation: The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

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? Contact the surgeon for debridement. Using sterile technique, debride the wound. Off-load pressure from the heel. Place an antiembolism stocking on the client's leg.

Off-load pressure from the heel. Explanation: 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 wound.

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. Explanation: 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 is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? The nurse places a foam wedge under the body to keep body weight off the client's back. The nurse uses a ring cushion to protect reddened areas from additional pressure. The nurse increases the amount of time the head of the bed is elevated. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. Explanation: Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Reference:

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. Explanation: 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.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To splint the area when engaging in activity To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing

To splint the area when engaging in activity Explanation: To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Use sterile gloves. 2Cut the foam to the shape and measurement of the wound. 3Place the drape to cover the wound and an additional 3 to 5 cm. 4Cut a 2-cm hole in the drape. 5Apply a vacuum device to wound. 6Ensure that negative pressure has been achieved.

Use sterile gloves. Cut the foam to the shape and measurement of the wound. Place the drape to cover the wound and an additional 3 to 5 cm. Cut a 2-cm hole in the drape. Apply a vacuum device to wound. Ensure that negative pressure has been achieved. Explanation: The correct order for the application of negative pressure wound therapy is as follows: apply sterile gloves; cut the foam to the shape and measurement of the wound; place the drape to cover the wound and an additional 3 to 5 cm; cut a 2-cm hole in the drape; apply vacuum device to the wound; and ensure that negative pressure has been achieved.

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 Explanation: Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.

A client's risk for the development of a pressure injury is most likely due to which lab result? albumin 2.5 mg/dL glucose 110 mg/dL hemoglobin A1C 7% sodium 135 mEq/L

albumin 2.5 mg/dL Explanation: 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 injuries.

Which client(s) is considered at risk for skin alterations? Select all that apply. an adolescent with multiple body piercings a client in a monogamous same-sex relationship a client receiving radiation therapy a client undergoing cardiac monitoring a client with diabetes

an adolescent with multiple body piercings a client receiving radiation therapy a client with diabetes Explanation: Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a sexual relationship with multiple gay male partners would also place a client at risk for HIV and skin alterations, but this client is in a monogamous relationship. Cardiac monitoring does not place a client at risk for skin alterations.

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 Explanation: A figure-of-eight turn is used for joints like the elbows and knees. The other answers are incorrect.

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? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing.

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 Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.

Which best describes the proliferative phase, the third phase of the wound healing process? the onset of vasoconstriction, platelet aggregation, and clot formation marked by vasodilation and phagocytosis as the body works to clean the wound reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound

reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization Explanation: 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 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? primary intention maturation secondary intention tertiary intention

secondary intention Explanation: Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

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

serosanguineous Explanation: This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

A client has been admitted to the acute care unit after surgery to debride 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? primary intention secondary intention tertiary intention quadratic intention

tertiary intention Explanation: 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.