Wound Care ch32

A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which of the following interventions should the nurse include in the plan to prevent the development of pressure ulcers? Select all that apply.

>Provide incontinent care every 2 hours and as needed >Turn client every 2 hours while client in bed >Encourage client to take fluids every 2 hours

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?

Biosurgical debridement

A client suffering from infectious diarrhea, dehydration, and right sided paralysis is confined to bed. What is the client most prone to?

Decubitus Ulcer

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage.

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

Document the findings

What type of dressing has the advantages of remaining in place for 3 to 7 days, resulting in less interference with wound healing?

Hydrocolloid dressings

The nurse is caring for a Penrose drain for a patient 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 and cuts off the end of the drain with sterile scissors.

Pressure ulcers are caused by unrelieved compression of the skin that results in damage to underlying tissues.

True

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

A Penrose drain promotes drainage passively into a dressing.

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

Fish

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

A nursing instructor is teaching a student nurse about the layers of the skin. Which of the following layers should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

Which of the following activities should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Support the client from sliding in bed

The nurse is caring for a patient who has a pressure ulcer on his back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair.

While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record?

Unintentional, partial-thickness wound

A nurse is assessing wound drainage during the immediate postoperative period for a patient who has had a breast removed. In addition to assessing the dressing, where would the nurse also check for drainage?

under the patient

The acute care nurse is caring for a patient whose large surgical wound is healing by secondary intention. The patient asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which of the following clients has the highest risk for developing a pressure ulcer?

65-year-old incontinent client with a hip fracture on bed rest

You are caring for a patient who has a heavy exudating wound that needs autolytic debridement. Which of the following wound dressings/products is most appropriate to use on the wound?

An alginate dressing, such as AlgiCell

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection

A client has developed blisters around the tape that secures the dressing. The nurse should

Apply the dressing with a binder

A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development?

Braden scale

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline and 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

Which of the following types of wound drainage should alert the nurse to the possibility of infection?

Foul-smelling drainage that is grayish in color

The nurse is caring for a client in the emergency department who cut herself while preparing dinner at her home. The nurse understands the client's wound is in which phase of the following phases of wound healing?

Hemostasis phase

In rhe elderly client, wrinkling is related to

Loss of elasticity

A nurse is caring for a client on a medical surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which of the following types of debridement does the nurse understand has been ordered on this client?

Mechanical debridement

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

Primary intention

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which of the following types of wound repair would the nurse expect with this wound?

Secondary intention

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

The nurse keeps the pad in place for 20 to 30 minutes assessing regularly

A nurse caring for a patient who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition?

There is an accidental separation of the wound.

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

Transparent

A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon.

True2

What is the most accurate definition of a wound?

a disruption in normal skin and tissue integrity

The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces?

A patient sitting in a chair who slides down

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

Albumin 2.8mg/dL

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

Do you experience incontinence?

The nurse observes the client for signs of Stage I pressure ulcer development, which is most likely to include which finding?

Nonblnchable redness

A nurse assessing the skin of patients knows that the following are health states that may predispose patients to skin alterations. Select all that apply.

Obesity Excessive perspiration Low BMI

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which of the following statements describes this phase of wound recovery?

Period during which the wound undergoes changes and maturation

A nurse is assessing a pressure ulcer 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 of the following stages should the nurse assign to this client's wound?

Stage III

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.)

>A wound that is characterized by oozing from the tissue covering the wound >A wound with drainage that is a beige color >A wound that requires wound cleaning and irrigation

A med-surg nurse is assessing wounds of patients. Which wound complications are accurately described below? (Select all that apply.)

>Dehiscence, which is present when there is a partial or total disruption of wound layers >Evisceration, which occurs when the viscera protrudes through the incisional area >Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site

A nurse assessing patient wounds would document which examples of wounds as healing normally without complications? (Select all that apply.)

>The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. >A wound that does not feel hot upon palpation >A wound that forms exudate due to the inflammatory response

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 dressing change on a deep upper-arm wound is painful for the patient. When preparing a care plan for the patient, the nurse will incorporate which nursing measure?

Plan to administer a prescribed analgesic 30-45 minures prior to the dressing change

A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which of the following drainage types should the nurse document?

Serosanguineous

A nurse is caring for a client with a nonhealing stage IV pressure ulcer. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. Which of the following is the correct term for this condition?

Undermining

The nurse is assessing the wounds of patients. Which patients would the nurse place at risk for delayed wound healing? (Select all that apply.)

>An older adult who is bed-ridden. >A patient with a peripheral vascular disorder >A patient who is obese >A patient who is taking corticosteroid drugs

When giving a back rub to an older patient at home, the nurse notices a stage II pressure ulcer. What nursing interventions would the nurse perform next?

Clean the wound with normal saline.

Which of the following actions should the nurse perform when applying negative pressure wound therapy?

Cut foam to the shape of the wound and place it in the wound

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

Dehiscence is when a wound has partial or total separation of the wound layers.

Which interventions might a nurse be expected to perform when providing competent care for a patient with a draining wound? (Select all that apply.)

>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

A nurse is caring for a client on a medical surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which of the following actions by the nurse are appropriate in this situation? Select all that apply.

>Cover wound with a gauze moistened with normal saline >Place client in low Fowler's position >Use sterile techniques

Which nursing interventions reflect the accurate use of heat or cold during wound care? (Select all that apply.)

>The nurse makes more frequent checks of the skin of an older adult using a heating pad. >The nurse fills an ice bag with small pieces of ice to about two-thirds full. >The nurse covers a cold pack with a cotton sleeve to keep it in a cold pack with a cotton sleeve to keep it in place on an arm.

A physician orders a wound irrigation to apply an antiseptic to a client's wound. The nurse will follow which guideline for performing this procedure?

If the wound is closed, clean technique may be used instead of sterile technique.

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 of the following actions should the nurse perform in obtaining a wound culture?

Keep the swab and inside of the culture tube sterile.