Wound care and dressing

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options

Put on clean gloves. Remove old dressing. Assess the wound bed. Open dressing materials. Irrigate the wound bed. Time and date the dressing.

The nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse?

Reinforce the dressing and assess site frequently

The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse?

Replace the dressing with a larger one.

What is the primary outcome the nurse expects when choosing Montgomery straps to secure a dressing?

The client's skin remains free from additional irritation or injury.

The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention?

Use Montgomery straps instead of adhesive tape to hold the dressing in place.

The nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation?

Use small amounts of sterile saline to help loosen and remove the dressing.

Which client would be at greatest risk for developing a pressure injury?

an adult client who is comatose

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next?

cleanse the wound with a nonantimicrobial cleanser

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding?

deep tissue injury

The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first?

obtain a sterile wound culture

Which client is a greatest risk of developing a pressure injury?

47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness

When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure?

Date and reuse leftover irrigation solution within 24 hours.

When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication?

Dehiscence.

The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound?

From the upper end of the wound to the lower end

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe?

Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury?

Raise the bed to elbow height.

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next?

Remove gloves and perform hand hygiene.

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding?

Stage 1 pressure injury

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply.

b. Full-thickness tissue loss c. No bone, tendon, or muscle visible. d. Visible subcutaneous fat

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 b/w dressing changes

What intervention should be performed by the nurse before applying Montgomery straps?

Apply a skin barrier to the site where the straps will be placed.

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 skin barrier at least 1 in (2.5 cm) away from the area of irritation

The nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation?

Assess for pain, shortness of breath, shortness of breath, and abdominal pressure.

The nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate?

Loosely pack the dampened dressing material to prevent too much pressure on the wound bed.

A client with an abdominal wound requires frequent dressing changes because of large amounts of drainage. Which should the nurse use to secure this dressing?

Montgomery straps

A nurse is working with a client who requires frequent changes of a wound dressing. Which equipment would allow the nurse to change the dressing without having to use tape?

Montgomery straps

The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution?

Sterile basin

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time?

Teach the client ways to relieve the pressure on the heel.

The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure?

The client's comfort and effectiveness of pain medication

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing?

To promote moist wound healing and protect the wound from contamination and trauma.

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development?

Turn and reposition the client every 2 hours.

When collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results?

a rolling motion

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure?

clean the wound

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound:

has black brown eschar covering the top.

a nurse is collecting a wound culture from two different site. Which of the following actions should the nurse take while performing this procedure? Select all that apply

insert swab into the wound place the swab in the culture tube when done press and rotate the swab several times over the wound surfaces

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure?

pat the wound dry w a sterile gauze sponge

After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the:

top to the bottom using a new gauze for each wipe.

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound?

when the solution from the wound flows out clear