273 Week 2 PrepU: Skin Integrity and Wound Care

The nurse is discussing home remedies for insect bites with a group of college students. The nurse correctly includes which remedy in the presentation? Chamomile Lavender Tree tea oil Aloe vera

Aloe vera Explanation: Lotions and gels containing aloe vera are widely accepted as adjuvants to standard medical topical treatments for wounds, especially minor burns, insect bites, dermatitis, and dry skin. Chamomile, lavender, and tea tree oils are commonly used for healing wounds.

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity? Check pressure points for redness after 60 minutes Limit fluid intake Use soap liberally when bathing Clean perineal area daily but do not bathe full body on a daily basis

Clean perineal area daily but do not bathe full body on a daily basis Explanation: Because activity of the sebaceous and sweat glands decreases, the skin will become dryer and the client may have pruritis. The perineal area should be washed daily but the nurse should avoid full bathing of the body on a daily basis. Harsh soaps should be avoided and only used sparingly. The fluid intake should be increased unless otherwise contraindicated by medical condition. Pressure points are not related to the action of sebaceous and sweat gland activity, but the pressure points should be checked for redness after 30 minutes. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1047

A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse? Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab Obtain the swab as prescribed and send it to the lab for culture Discard the swab and inform the health care provider that the wound is too infected to culture Obtain the swab and then clean the wound

Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab Explanation: When the nurse has inserted the culture swab into the patient's wound to obtain the specimen and realizes that the wound was not cleaned: Discard this swab. Obtain the additional supplies needed to clean the wound according to facility policy and a new culture swab. Cleaning the wound prior to obtaining a specimen for culture Cleaning the wound removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, resulting in inaccurate results. Clean the wound using a nonantimicrobial cleanser and then proceed to obtain the culture specimen. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1115

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?

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 recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

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 evaluating a client who was admitted with partial-thickness (second-degree) burns. Please describe this type of burn?

Moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Explanation: Partial-thickness (second-degree) burns are moderate to deep burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Superficial (first-degree) burns may be pinkish or red with no blistering. Full-thickness (third-degree) burns vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

A client who was injured when stepping on a rusted 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 Explanation: Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defense against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.

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?

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.

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

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1047

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? Penrose drain Jackson-Pratt drain Wound pouching Hemovac drain

Penrose drain Explanation: Penrose drains are commonly used after a surgical procedure or to drain an abscess. Jackson-Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is typically placed into a vascular cavity where blood drainage is expected after surgery, and wound pouching is used on wounds that have excessive drainage. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1064

The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What are the appropriate nursing responses? Select all that apply. "The choice regarding whether to have or decline this treatment is yours." "We have to do this treatment to help your wound heal." "If you do not have this debridement, you will get septicemia and possibly die." "I understand your concern; let's talk further about your thoughts about this treatment." "Medical maggots are sterilized before they are introduced to the wound."

"Medical maggots are sterilized before they are introduced to the wound." "I understand your concern; let's talk further about your thoughts about this treatment." "The choice regarding whether to have or decline this treatment is yours." Explanation: Providing information about sterilization of the maggots may alleviate the client's concern about the creatures' condition. It is therapeutic of the nurse to allow the client to express concerns and to exercise autonomy in decision-making about treatment. It is nontherapeutic to insist that treatment be done (which also impedes the client's autonomy) and to frighten the client with the thoughts of septicemia and death.

A client has undergone an open surgical procedure. Which teaching provided by the nurse accurately reflects what the client should expect during the remodeling period? "The wound will contract and scarring will shrink." "Neutrophils and monocytes will migrate to the site of your incision." "Granulation tissue will start to form." "Blood vessels will constrict to control blood loss."

"The wound will contract and scarring will shrink." Explanation: Constriction of blood vessels and appearance of polymorphonuclear leukocytes take place during the inflammation period. Granulation tissue forms during the proliferation period. The surgical wound contracts and scarring shrinks during the remodeling period. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 31: Skin Integrity and Wound Care, p. 963. Chapter 32: Skin Integrity and Wound Care - Page 963

A nurse is caring for an adult who had Mohs surgery on the nose. The client asks, "Is there anything I can do to prevent getting skin cancer again?" How should the nurse respond? "I am so sorry, there are preventative measures such as limiting your exposure to UVA and UVB rays; however, since you have had skin cancer I am uncertain this would help you. You should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." "Absolutely, skin cancer can be prevented by limiting exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing." "There are preventative measures you should take to limit exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." "There are preventative measures you should take to limit exposure to UVA and UVB rays, such as only going outside when there is cloud cover; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended."

"There are preventative measures you should take to limit exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." Explanation: The client should be educated about the importance of preventing skin cancer by limiting exposure to UVA and UVB rays. The use of clothing, such as long-sleeve shirts, wide-brimmed hats, and sunglasses, in addition to the use of sunscreen should be encouraged. Preventative measures are not an absolute guarantee that a client will not get skin cancer, and someone who has been diagnosed previously with skin cancer is at greater risk. UVA and UVB rays can penetrate clouds, only going out on cloudy days will not protect the skin from exposure.

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." Explanation: The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? O A large wound with considerable tissue loss allowed to heal naturally O A wound healing naturally that becomes infected. O A surgical incision with sutured approximated edges O A wound left open for several days to allow edema to subside

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.

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 pads over the wet gauze and place the abdominal pad over the gauzes. 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. 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1096-1100

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 over the area of irritation to prevent further injury. Apply skin barrier only on the side of the wound without any irritation. Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. Apply skin barrier only on the right side of the wound over the irritation.

Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. Explanation: The skin barrier should be placed at least 1 in (2.5 cm) away from the area of irritation and should be placed on both sides of the wound. Skin barrier should not be placed over the area of irritation; it should only be placed on skin that is intact. The skin barrier should be applied to both sides of the wound as the Montgomery straps are applied to both sides of the wound on the intact skin surrounding the wound and 1 in (2.5 cm) away from any irritated or nonintact skin. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1105

The nurse is discussing traditional cultural beliefs relating to skin care and healing with a group of nursing students. Which remark by a participant indicates the need for further instruction? Asian culture often embraces the use of acupuncture. Body image is of little importance to the traditional French cultural beliefs. Native Americans often believe in the use of herbal or spiritual therapy. Canadians traditionally are concerned about the cost of medical treatment.

Body image is of little importance to the traditional French cultural beliefs. Explanation: Specific cultural differences were identified in a study regarding wound-related pain experiences: French participants expressed concern about body image, British participants were concerned about medication use, and Canadian participants were anxious about financial considerations related to wound care. Native American tribes often recognize an elder who specializes in specific healing rituals, which may include herbal or spiritual therapy to heal wounds. Asian cultures frequently use acupuncture to stimulate wound healing. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.

Which is not considered a skin appendage? Hair Sebaceous gland Connective tissue 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1042

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 Explanation: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

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 Explanation: When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.

When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse? Send the client to the emergency room. Document the findings. Consult a wound care nurse. Notify the physician.

Document the findings. Explanation: The nurse should document the findings. The red tissue that bleeds easily is granulation tissue, a key part of the healing process. As the wound is healing, there is no need to contact the physician or the wound care nurse. There is also no need to send the client to the emergency room. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1100-1101

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. Touch the swab to the intact skin at the wound edges. Use the same swab for both wound sites. Insert a swab into the wound. Place the swab in the culture tube when done. Tap the outside of the culture tube with the swab before placing it in the tube. Press and rotate the swab several times over the wound surfaces.

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: Chapter 32: Skin Integrity and Wound Care - Page 1112-1116

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. Explanation: The swab and the inside of the culture tube should be kept sterile prior to the procedure. 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.

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. Skin moisture Sensory perception Stages of pressure injuries Mental status Nutritional status

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1093-1095

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client? Placing the client in the supine position with a pillow under the knees Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs Placing the client in a wheelchair with the back of the feet resting against the heel loops Placing the client in a side-lying position with a pillow between the lower legs

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs Explanation: Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues. Pressure points in bed vary depending on the size and shape of client and the position. Pressure points while sitting in a chair or wheelchair also vary depending of the style, shape, and construction of the chair or wheelchair, the clients position in the chair, and the size and shape of the client. Any boney prominence or areas under a large amount of pressure against a hard or semihard surface can create a pressure injury. To protect clients at risk for pressure injury, the nurse implements a 2-hour turn schedule, uses a pressure redistribution support surface, keeps pressure points from pressing on the bed or chair by using positioning devices or pillows, keeps boney prominences from rubbing on each other, minimizes exposure of skin to incontinence, perspiration, or wound drainage, and provides adequate calories and nutrients. A pillow placed between the lower legs in side-lying position will prevent ankle to ankle pressure, but not ankle to mattress pressure. Placing a pillow under the knees while positioned supine will increase pressure on the heels. While using a wheelchair, it is best to have the client wear well-fitted shoes and position the feet on the footplate and remove the heel rest or heel loop. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1048

Question 18 of 20 The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action? Recompress the drain before replacing the cap. Cleanse the area around the cap with alcohol for 30 seconds before removing it. Pin the drain to the client's gown after pulling the tubing taut. Don sterile gloves before manipulating the cap of the drain.

Recompress the drain before replacing the cap. Explanation: Recompressing the drain after replacing the cap would force air and exudate into the client, causing pain and posing an infection risk. Gloves are necessary for this procedure, but they do not need to be sterile. It is unnecessary to cleanse the area around the cap with alcohol. It is important that the tubing should not be under tension.

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

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1096-1101

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. Explanation: The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II Explanation: A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

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 III Explanation: Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss, such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? Maintains a moist environment Keeps the wound clean Reduces swelling and inflammation Supports the area around the wound

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1077

A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product? The dressing allows for absorption of drainage. The dressing provides a sterile wound environment. The dressing allows oxygen exchange between the wound and environment. The dressing may safely be left in place for up to 10 days.

The dressing allows oxygen exchange between the wound and environment. Explanation: Transparent films allow for oxygen exchange between the wound and the environment. They do not absorb any drainage and they are normally left in place for up to 72 hours. Sterility is not conferred simply by the application of a wound dressing. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1073-1074

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. The nurse may delegate this task to unlicensed assistive personnel (UAP). The nurse should remove the staples in sequence, beginning at the proximal edge of the wound. The nurse should thoroughly irrigate the wound 15 to 30 minutes before the procedure.

The nurse should apply adhesive wound closure strips after removing staples. Explanation: After skin staples are removed, adhesive wound closure strips are applied across the wound to keep the skin edges approximated as the wound continues to heal. This task cannot be delegated to UAP. Irrigation is not necessary and alternating staples should be removed to prevent dehiscence. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1082

A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate an infection? The wound base appears yellow, with serosanguineous drainage, and the client's oral temperature is 101.5° (38.6° C). The wound base appears yellow, with serous drainage, and the client's oral temperature is 99°F (37.2° C). The wound base appears swollen and red, with yellow purulent drainage, and the client's oral temperature is 99°F (37.2° C). The wound base appears pink to red, with serous drainage, and the client's oral temperature is 101.5°F (38.6° C).

The wound base appears swollen and red, with yellow purulent drainage, and the client's oral temperature is 99°F (37.2° C). Explanation: Signs and symptoms of infection of a wound are local pain, redness, swelling, induration, or purulent drainage, or systemic symptoms, such as elevated leukocyte count or fever. A fever alone may not indicate that the wound is infected, the client could have an infection elsewhere, for example a urinary tract infection. A normal wound base appears pink to red for viable tissue, white to yellow for nonviable tissue, or brown to black for dead tissue. Normal drainage is serous, sanguineous, or serosanguineous. Purulent drainage occurs when an infection is present. It can vary in color depending on the microorganism and is thick and opaque. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1047

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk? a client 75 years of age who uses a cane and has dementia a client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history a client 68 years of age who is bedfast related to severe head trauma a client 45 years of age who has paraplegia

a client 68 years of age who is bedfast related to severe head trauma Explanation: Most pressure injuries occur in adults older than 65 years as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The resident who is bedfast would be most at risk in this situation due to the inability to move around and fecal and urinary incontinence while in the bed. The incontinent 92-year-old client is still mobile and though incontinent able to recognize when it is time to change the incontinent appliance. The 45-year-old client with paraplegia is someone that would need to be monitored for potential issues; however, with proper education about causes of pressure injuries, positioning strategies, and equipment to assist with mobility, such as a bed trapeze, the 45-year-old client is not a higher risk than the client who is bedfast. The 75-year-old client with dementia is mobile and not a higher risk than the client who is bedfast. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1065

A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider? hydrocolloid alginate transparent hydrogel

alginate Explanation: Alginates are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue. Hydrogels are used with dry wounds or wounds with minimal drainage. Hydrocolloids are used with light to moderate drainage in wounds with necrosis or slough. Transparent dressings are used with wounds having minimal drainage, small size, and partial thickness. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1073

The nurse is providing care to an older adult client. Which intervention(s) will the nurse perform to protect the client's skin? Select all that apply. offer fluids every hour while the client is awake wash the perineal area every day provide a bed bath every day apply moisturizing lotion to feet and hands daily minimize the use of any tape on the skin

apply moisturizing lotion to feet and hands daily minimize the use of any tape on the skin wash the perineal area every day offer fluids every hour while the client is awake Explanation: Nursing interventions to protect the older adult client's skin include applying moisturizing lotions to feet and hands. This is because the older client's skin becomes more dry as the person ages. The nurse protects the skin from injury by minimizing the use of tape on the skin. The older adult client's skin is more easily injured. The nurse washes the perineal area daily and as needed to clean the skin of urine and feces. Both are irritants to the skin and may cause damage. The nurse offers fluids to the client to ensure adequate hydration, which helps protect the skin. The nurse does not bathe the older client every day, since this will cause the skin to become more dry. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1047

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 action by the nurse is appropriate in this situation? Select all that apply. using sterile technique placing the client in the low Fowler position packing the wound with iodoform gauze covering the wound with a gauze moistened with normal saline reinserting the protruding structures and applying a pressure dressing

covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position using sterile technique Explanation: Evisceration of a wound is a medical emergency. The client should be placed in a low Fowler position and, with the use of sterile technique, the eviscerated structures should be covered with normal saline-moistened gauze. The surgeon should also be notified. The nurse should never reinsert protruding structures or apply a pressure dressing. This could cause the tissue to be injured. The wound should not be packed with iodoform gauze. The client will have surgery to replace the eviscerated structures. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1053

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? large amounts of drainage that is clear and watery and has no smell foul-smelling drainage that is grayish in color copious drainage that is blood-tinged 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

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 type of debridement does the nurse understand has been ordered on this client? autolytic debridement enzymatic debridement biosurgical debridement mechanical debridement

mechanical debridement Explanation: Mechanical debridement involves physical removal of necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1072

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 statement describes this phase of wound recovery? physiologic defense immediately after the tissue injury process by which damaged cells recover and reestablish normal function period during which new cells fill and seal a wound period during which the wound undergoes changes and maturation

period during which the wound undergoes changes and maturation Explanation: The remodeling phase can be described as the period during which the wound undergoes changes and maturation. The remodeling phase follows the proliferative phase and may last 6 months to 2 years. The inflammatory phase is the physiologic defense immediately after tissue injury. The proliferation phase is the period during which new cells fill and seal the wound. Resolution is the process by which damaged cells recover and reestablish normal function. This forms part of the proliferation phase. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1048

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply. pull the client up in bed as needed encourage the client to take fluids every 2 hours turn the client every 2 hours when the client is in bed provide incontinent care every 2 hours and as needed elevate the head of the bed 90 degrees four times daily

provide incontinent care every 2 hours and as needed turn the client every 2 hours when the client is in bed encourage the client to take fluids every 2 hours Explanation: Nursing interventions that will decrease the risk of pressure injury development include incontinent care every 2 hours and as needed, turning the client every 2 hours, and encouraging fluids every 2 hours. Factors that lead to pressure injury development include external pressure, friction, shear, immobility, inadequate nutrition and hydration, skin moisture, mental status, and age. Elevating the head of the bed 90 degrees four times daily increases pressure to the coccyx and sacral area and causes shearing. Pulling a client up in bed as needed should be avoided, as this causes shear. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1081

The client twisted his ankle while hiking in an isolated area. The client reports pain and is unable to bear weight on the ankle. A nurse who is present has conducted an assessment and recommended the client rest and elevate the leg while waiting for rescue. The nurse is applying to the ankle a commercially prepared ice pack that contains a chemical. What precautions would the nurse employ when applying cold therapy to the client's ankle? Select all that apply. place a cloth between the ice pack and the skin assess the client's ankle skin frequently squeeze the nonfrozen chemical pack to activate keep the ice pack applied to the skin for at least 1 hour ask the client about numbness and pain related to the cold therapy

squeeze the nonfrozen chemical pack to activate assess the client's ankle skin frequently ask the client about numbness and pain related to the cold therapy place a cloth between the ice pack and the skin Explanation: Commercially prepared ice packs that contain a chemical are activated by squeezing the ice pack. During an application of cold therapy, the nurse assesses the skin and asks the client about pain and numbness. The nurse places a cloth between the ice pack and the skin to prevent injury caused by the cold pack. The ice pack is applied for 30 minutes and removed for 1 hour prior to reapplication. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1086

A client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching, what will the nurse provide to the client to prepare for the appointment?

"Do not douche for 24-48 hours before the procedure." Explanation: Clients should be informed to refrain from douching 24-48 hours prior to a Pap test, as this can wash away diagnostic cells. The healthcare provider is unlikely to recommend routine douching; this procedure is usually used to assist with treatment of an infection. The Pap procedure involves obtaining cell samples.

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?" 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). 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.

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 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 nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands? "I will squeeze the chamber and apply the cap to maintain negative pressure." "I will apply a dressing at the end of the drain to catch any drainage." "I will check and empty the drain every 6 hours." "I will alternate between positive and negative pressure every 2 hours."

"I will squeeze the chamber and apply the cap to maintain negative pressure." Explanation: The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain has gauze at the end of the drain to catch drainage. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1079

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

"It is important to keep your sutured incision clean." Explanation: After a cesarean birth, a client will be sutured and have staples put in place for a number of days. It is important to keep the sutured incision clean.

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?

"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 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 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.

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform?

-Administer analgesia before changing the dressing around the drain, if needed. -Use a gauze pad to clean the drain outlet after emptying it. -Fasten the drain to the client's gown using a safety pin after emptying and recompressing it. Explanation: Analgesia can be provided before drain care, if necessary. A gauze pad is used to cleanse the outlet after emptying and the drain is secured to the client's gown with a safety pin.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. What are they?

-The volume of circulating blood must be sufficient. -The heart must be able to pump adequately. -Arteries and veins must be patent and functioning well.

client has a fissure on her finger due to chafing. The client asks, "How long will it be painful?" The nurse explains that the inflammation phase will last: 3 days. 7 days. 5 days. 2 weeks.

3 days. Explanation: The inflammation phase of a partial-thickness wound lasts approximately 3 days. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,

A nurse is using the RYB wound classification system to document client wounds. Which wound would the nurse document as a Y (yellow) wound? Select all that apply. A wound that reflects the color of normal granulation tissue A wound that requires wound cleaning and irrigation 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 is covered with thick eschar A wound that is treated by using sharp, mechanical, or chemical debridement

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 Explanation: The nurse would document a wound that is characterized by oozing from the tissue covering the wound as a Y (yellow) wound. The nurse would document a wound that has beige colored drainage and a wound that requires wound cleaning and irrigation as Y (yellow) wounds. A wound that reflects the color of normal granulation tissue would be an R (red) wound. A wound that is covered with thick eschar would be documented as a B (black) wound. A wound that is treated by using sharp, mechanical, or chemical debridement would be documented as a B (black) wound. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

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 incision site. Apply a skin protectant to the skin around the incision. 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1082

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?

As a stage I pressure injury Explanation: Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone.

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. Explanation: Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.

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

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 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?

Discontinue the therapy and assess the client. Explanation: The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event.

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

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: Chapter 32: Skin Integrity and Wound Care - Page 1100-1101

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? O Green beans O Banana O Fish O Pasta salad

Fish Explanation: To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote 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 Explanation: Gauze dressings absorb blood or drainage. Transparent dressings are used to protect intravenous insertion sites. Hydrocolloid dressings are used to used keep a wound moist. Adhesive strips with eyelets are used to secure a gauze dressing that needs frequent changing.

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. 4Inflammatory 1Hemostasis 2Proliferation 3Maturation SUBMIT ANSWER

Hemostasis Inflammatory Proliferation Maturation Explanation: The correct order of the phases of wound healing is hemostasis, inflammatory, proliferation, and maturation. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1049-1050

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 Risk for Infection related to wound Pain related to wound sustained by knife Knowledge Deficit regarding wound care related to laceration

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1048

The nurse is performing wound care on a client with an open fracture. What is the nurse's priority action to clean the wound?

Irrigate the wound with normal saline. Explanation: Irrigation of the wound to wash out debris as well as devitalized tissue would be the priority action in cleaning the wound. Pain medication would improve the client's tolerance of the procedure but not actually have an effect on cleaning the wound. Elevating the foot of the bed would decrease edema and improve circulation. Use of antibiotic ointment would follow the cleaning of the wound as a method to prevent infection.

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? Red Yellow White Blue-grey

Red Explanation: Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1053

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. Explanation: The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection.

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?

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.

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? Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of a structure from its normal position Tearing of the skin and tissue with some type of instrument; tissue not aligned 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: Chapter 32: Skin Integrity and Wound Care - Page 1048

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound. Explanation: The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.

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 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.

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?

Transparent film Explanation: To secure an IV catheter, the nurse uses a transparent film. The transparency film allows visualization of the IV site, is self-adhesive, and protects against contamination.

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

Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury?

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

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1066

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? puncture incision avulsion contusion

contusion Explanation: A contusion is an injury to soft tissue, so this is what the nurse expects to see on the basis of the teacher's description of the incident. A puncture involves an opening in the skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripping of the surface layers of skin. In an avulsion injury, large areas of skin and underlying tissues have been stripped away. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1048

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? wrapping distally to proximally elevating and supporting the stump keeping the bandage free of gaps between turn exerting equal, but not excessive, tension with each turn of the bandage

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1077

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

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

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? improving the client's hydration pulling the client up from under the arms lubricating the area with skin oil preventing the client from sliding in bed

preventing the client from sliding in bed Explanation: Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1055

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 IV stage III stage I stage II

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.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: to provide a sinus tract for drainage. to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity. to provide drainage for bile.

to provide drainage for bile. Explanation: A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1064

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? transparent adhesive strips with eyelets gauze 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1073

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? transparent gauze adhesive strips with eyelets 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1073

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 the wound for active bleeding Explanation: Negative-pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed. NPWT is not considered for use in the presence of active bleeding.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Unstageable Yellow classification Black classification Red classification

Black classification Explanation: A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1050

The nurse is caring for a Penrose drain for a client 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 empties and suctions the device, following the manufacturer's directions prior to shortening the drain. The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain. The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain.

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. Explanation: Sometimes the physician orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1079

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? 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 uses wet-to-dry dressings continuously.

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1072

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

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1082

The nurse is preparing to measure the depth of a client's tunneled wound. What should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use.

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing? maturation phase inflammatory phase hemostasis phase proliferation phase

hemostasis phase Explanation: Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and release growth factors. The proliferation phase is the regenerative phase, in which granulation tissue is formed. The maturation phase involves collagen remodeling. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1049

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 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 client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues? applying skin barrier to protect the skin applying tape to the side of the blisters applying the dressing with a binder using paper tape on the blisters

applying the dressing with a binder Explanation: Bandages, binders, and stretch nets also can be used to hold gauze dressings in place and will prevent further damage to the tissues. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1075

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. 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.

A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition? undermining dehiscence slough eschar

undermining Explanation: Undermining is the term for a hollow area between the outer wound and the wound bed. It resembles a cave. Eschar is a leathery covering that is dead tissue; it is usually removed by debridement. Tunneling is a cavity or channel formed from a wound. Dehiscence is the opening of a previously closed surgical wound. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1084

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:

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 considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? O A client who must remain on the back for long periods of time O A client who lifts himself up on the elbows O A client who lies on wrinkled sheets O A client sitting in a chair who slides down

a client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down.

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. a 10-year-old client with a surgical incision a client with a peripheral vascular disorder an older adult who is confined to bed a client who is obese a client who eats a diet high in vitamins A and C a client who is taking corticosteroid drugs

an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drugs Explanation: There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure injury formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client. A client who eats a diet high in vitamins A and C would not be at risk for delayed wound healing. A 10-year old client with a surgical incision would not be at risk for delayed wound healing. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1051

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. "This is a simple reparative process." "Very little scar tissue will form." "Your wound edges are right next to each other." "The margins of your wound are widely separated." "Your wound will be purposely left open for a time."

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other." Explanation: Very little scar tissue is expected to form during first-intention healing in a wound whose wound edges are close to each other. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1048

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?

1. Remove the soiled dressing wearing clean gloves. 2. Clean the wound, wearing sterile gloves and using sterile supplies. 3. Dry the surrounding tissue with gauze. 4. Insert the culture swab deep into the wound, wearing clean gloves. 5. Using a different pair of gloves, place a clean dressing on the wound. Explanation: When obtaining a culture of a wound, the nurse first removes the soiled dressing, if present, wearing clean gloves. Using sterile gloves and sterile supplies, the nurse cleanses the wound. This is an acute injury, not a chronic wound, and therefore requires sterility. Cleaning the wound removes previous drainage and wound debris that could cause inaccurate culture results. The nurse removes moisture from the surrounding skin that would provide a medium for growth of microorganisms. The nurse now obtains the culture. With a fresh pair of gloves, the nurse places a dressing on the wound.

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? Acute pain Impaired tissue integrity Knowledge deficit Disturbed body image

Impaired tissue integrity Explanation: Using the A, B, C (Airway, Breathing, Circulation) mnemonic, impaired tissue integrity takes priority. Using Maslow's Hierarchy of Needs, impaired tissue integrity also takes priority. Disturbed body image, knowledge deficit, and acute pain are all important issues that need to be addressed, but ensuring there is proper circulation to the surgical area, the surgical area is free of signs of infection, and the surgical area is intact is priority. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1066

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? Off-load pressure from the heel. Contact the surgeon for debridement. Using sterile technique, debride the wound. 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

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 detergent. a rash related to immobility. an allergic reaction to medications. a rash related to a yeast infection.

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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1046

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? maturation secondary intention tertiary intention primary 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 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 with a new gauze for each stroke cleanse the wound in parallel strokes from the top to the bottom of the wound 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 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1098

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?

Incision Explanation: An incision is a clean separation of skin and tissue with smooth, even edges. Therefore the nurse documents the finding as an incision. In an avulsion, large areas of skin and underlying tissue have been stripped away. An abrasion involves the stripping of the surface layers of skin. A laceration is a separation of skin and tissue with torn, irregular edges. Therefore the nurse does not document the finding as an avulsion, abrasion, or laceration.

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. O A client who is obese O An older adult who is confined to bed O A 10-year-old client with a surgical incision O A client who is taking corticosteroid drugs O A client with a peripheral vascular disorder O A client who eats a diet high in vitamins A and C

-An older adult who is confined to bed -A client with a peripheral vascular disorder -A client who is obese -A client who is taking corticosteroid drugs Explanation: There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure injury formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client.

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 sterile gauze sponge over the incision site. Apply a skin protectant to the incision site. Apply a skin protectant to the skin around the incision. 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. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1082

A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document? Staging of the surgical wound Cardiac and respiratory function Length, width, and depth of the wound Presence of abnormalities that would impede healing

Presence of abnormalities that would impede healing Explanation: An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. The nurse should make sure the client is assessed for the presence of abnormalities that would impede healing, such as signs and symptoms of infection, poor circulation below the surgical sight, adequate nutrition, and medications the client may be taking that interfere with healing. The size of the surgical wound would not include depth because of the presence of staples. Cardiac and respiratory assessment would not be the focus for a client after surgical knee replacement, unless the client reported concerns in those areas. Staging is only done on pressure injury wounds. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1051

While walking in the woods, an 8-year-old child trips and a stick cuts the right leg with partial-thickness involvement. What would the camp nurse observe and document about the child's wound? The wound was intentional due to fall, and the dermis, sweat glands, and hair follicles are not present. The wound is caused accidentally, and the dermis, sweat glands, and hair follicles are not present. The wound is caused accidentally, and all or a portion of the dermis is intact. The wound was purposely created from impact of the fall, and all or a portion of the dermis is intact.

The wound is caused accidentally, and all or a portion of the dermis is intact. Explanation: The child sustained an unintentional, partial-thickness wound. An unintentional wound is an accidental wound. An intentional wound is one created for a purpose, like a surgical wound. A partial-thickness wound is characterized by all or a portion of the dermis remaining intact. A full-thickness wound is characterized by severing of the entire dermis, sweat glands, and hair follicles. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 960. Chapter 32: Skin Integrity and Wound Care - Page 960

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding? visible subcutaneous fat exposed bone with eschar nonblanchable redness a shallow open injury

nonblanchable redness Explanation: A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. A stage II pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer. A stage III pressure injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. A stage IV pressure injury involves full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often includes undermining and tunneling. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1056

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?

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.