Chapter 16
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.
1Hemostasis 2Inflammatory 3Proliferation 4Maturation
A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings? Diffuse dermatitis accompanied by pruritus Superficial contusion accompanied by pruritus Diffuse fungal infection accompanied by pruritus Superficial abscess accompanied by pruritus
A
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? Assess the client's wound and vital signs. Administer the prescribed analgesic. Notify the health care provider of the pain. Document the pain and vital signs.
A
A client's risk for the development of a pressure injury is most likely due to which lab result? albumin 2.5 mg/dL glucose 110 mg/dL hemoglobin A1C 7% sodium 135 mEq/L
A
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? a client sitting in a chair who slides down a client who lifts himself up on the elbows a client who lies on wrinkled sheets a client who must remain on the back for long periods of time
A
A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon applying sterile dressings with normal saline over the protruding organs and tissue assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound
B
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."
B
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? Glasgow scale Braden scale FLACC scale Morse scale
B
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? elevate the head of the bed 90 degrees use pillows to maintain a side-lying position as needed provide incontinent care every 4 hours as needed place a foot board on the bed
B
A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? Gentle cleansing Wound irrigation Debridement Apply moist dressing
B
A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: infection. herniation. dehiscence. evisceration.
C
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? stage I stage II stage III stage IV
D
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 Knowledge deficit Disturbed body image Impaired tissue integrity
D
The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? circular turn spiral-reverse turn spica turn figure-of-eight turn
D
A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? Supports the area around the wound Maintains a moist environment Keeps the wound clean Reduces swelling and inflammation
A
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? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood
A
An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: milia. prickly heat. acne vulgaris. lanugo.
A
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a surgical incision with sutured approximated edges a large wound with considerable tissue loss allowed to heal naturally a wound left open for several days to allow edema to subside a wound healing naturally that becomes infected.
A
The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force? preventing the client from sliding in bed pulling the sheets to reposition the client every 2 hours improving the client's hydration pulling the client up from under the arms
A
A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done. Use the same swab for both wound sites. Touch the swab to the intact skin at the wound edges. Tap the outside of the culture tube with the swab before placing it in the tube.
A, B, C
The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? stage I stage II stage III stage IV
B
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? Pasta salad Fish Banana Green beans
B
The nurse is caring for a client who has recently noted abnormal pigmentation in his skin. What is most likely deficient in the client's diet? Vitamin A Vitamin B12 Zinc Magnesium
C
What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? Secure the drain to the client's gown with a safety pin below the level of the wound. Tape the drain to the dressing material securely below the level of the wound. Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. Apply an abdominal binder over the entire wound and drain to support the site.
A
The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who eats a diet high in vitamins A and C a client who is taking corticosteroid drugs a 10-year-old client with a surgical incision
A, B, C, E
What should the nurse assess before application of sitz bath therapy? Select all that apply. Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void Client's serum sodium levels
A,B,C,D
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? removing dead or infected tissue to promote wound healing stimulating the wound bed to promote the growth of granulation tissue removing purulent drainage from the wound bed in order to accurately assess it removing excess drainage and wet tissue to prevent maceration of surrounding skin
A
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A Penrose drain promotes passive drainage into a dressing. A Penrose drain is a closed drainage system that is connected to an electronic suction device. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.
A
The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client? Monitor intake and output. Assess the coccyx area for blanching. Monitor the client for nausea. Assess mental status.
A
Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply. The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse places a heating pad on a sprained wrist that is in the acute stage. The nurse instructs the client to lean or lie directly on the heating device. The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. The nurse applies moist cold to a client's eye for 40 minutes every 2 hours.
A, D, E
The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. Fill the bowl of the sitz bath about halfway full with tepid to warm water. Insert tubing into the infusion port of the sitz bath. Slowly unclamp the tubing and allow the sitz bath to fill. Ensure that the call bell is within reach. Hang the bag of tepid to warm water at the client's chest height on an IV pole. Have the client soak for about 50 to 60 minutes.
A,B,C,D
An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor? The client's size limits his activity level. Adipose tissue is poorly vascularized. Obesity is linked to impaired white blood cell function. The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.
B
The nurse is preparing to change a large abdominal dressing in which blood and drainage is expected. In addition to gauze, which dressing supply will the nurse gather to take in the client's room? transparent adhesive strips with eyelets gauze hydrocolloid
B
The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Allow the wound and intestinal contents to remain open to air. Apply saline solution-moistened gauze over the protruding area. Pack the wound with gauze pads and a dry sterile dressing. Inform the client that this is an expected occurrence and not to worry.
B
Which is not considered a skin appendage? Hair Connective tissue Sebaceous gland Eccrine sweat glands
B
A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? primary intention secondary intention tertiary intention quadratic intention
C
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 should thoroughly irrigate the wound 15 to 30 minutes before the procedure. 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.
A
A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple is removed. Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision.
A
An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site? a transparent film a gauze dressing precut halfway to fit around the IV line a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics
A
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? a sterile, flexible applicator moistened with saline a small plastic ruler a sterile tongue blade lubricated with water soluble gel an otic curette
A
A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? Notify the surgeon STAT Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon
B
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 check and empty the drain every 6 hours." "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 alternate between positive and negative pressure every 2 hours."
B
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.
C
A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? serous purulent serosanguineous sanguineous
C
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? Red classification Yellow classification Black classification Unstageable
C
A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has prescribed fly larvae to debride the wound. Which type of debridement does the nurse understand has been prescribed? autolytic debridement surgical (sharp) debridement enzymatic debridement mechanical debridement
D
A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care? cleanse the wound from the outer area toward the inner area cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing cleanse the wound in parallel strokes from the top to the bottom of the wound cleanse with a new gauze for each stroke
D
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "This is normal tissue." "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing."
D
The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Avoid using irrigation to clean the wound before changing the dressing. Apply dry gauze to the wound and carefully apply saline to saturate it. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.
D
The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? The nurse elevates the foot of the bed. The nurse uses a ring cushion to protect reddened areas from additional pressure. The nurse increases the amount of time the head of the bed is elevated. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.
D
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Utilize the culture swab to obtain cultures from multiple sites. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
D
A full-thickness or third-degree burn develops a leathery covering called a(an): eschar. static. abrasion. erythema.
A
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? contusion incision avulsion puncture
A
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? The nurse works outward from the wound in lines parallel to it. The nurse uses friction when cleaning the wound to loosen dead cells. The nurse swabs the wound with povidone-iodine to fight infection in the wound. The nurse swabs the wound from the bottom to the top.
A
The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? Apply a skin protectant to the skin around the incision. Apply a skin protectant to the incision site. Apply a sterile gauze sponge over the incision site. Apply a transparent dressing over the incision site.
A
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? Reduce the time interval between dressing changes. Assure that the packing material is completely saturated when placed in the wound. Use less packing material. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. TAKE ANOTHER QUIZ
A
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. Notify the health care provider of the findings. Document the findings in the client's medical record. Gently rub and massage the area to warm it up.
A
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? "Very little scar tissue will form." "This is a complex reparative process." "The margins of your wound are not in direct contact." "The surgeon will leave your wound open intentionally for a period of time."
A
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
A
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "Do you experience incontinence?" "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?"
A
Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select? Hydrocolloid Wet to dry Negative wound pressure therapy Telfa
A
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To splint the area when engaging in activity To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing
A
When applying an external heating pad, which prescription from the health care provider would the nurse question? Leave heating pad on for 45 minutes Assess site frequently during application of the heating pad Use gauze to secure the heating pad to the site of application Maintain the temperature between 105°F to 109°F (40.5°C to 43°C)
A
Which action should the nurse perform when applying negative pressure wound therapy? Cut foam to the shape of the wound and place it in the wound. Increase the negative pressure setting until drainage is brisk. Irrigate the wound thoroughly using normal saline and clean technique. Test the seal of the completed dressing by briefly attaching it to wall suction.
A
A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For which type(s) of injury would the nurse be alert? Select all that apply. Broken left ankle Abrasions Soft tissue damage Concussion Bruising
A, B, C, D, E
A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. Fingers with quick capillary refill Warm hand Decreased radial pulse Cyanosis No finger numbness or tingling
A,B,E
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 provide drainage for bile. to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity.
B
What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing? transparent film hydrocolloid hydrogel alginate
B
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. elevate the head of the bed 90 degrees four times daily provide incontinent care every 2 hours and as needed pull the client up in bed as needed turn the client every 2 hours when the client is in bed encourage the client to take fluids every 2 hours
B,D,E
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Use clean technique to clean the wound. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Clean the wound from the top to the bottom and from the center to outside. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.
C
A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development? Hemoglobin A1C 5% Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L) Albumin 2.8 mg/dL (28.0 g/L) White blood cell count 14,800 mm3 (14.8 x 109/L)
C
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? primary intention maturation secondary intention tertiary intention
C
A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? Epidermis Dermis Subcutaneous tissue Muscle layer
C
A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: an allergic reaction to medications. an allergic reaction to detergent. a rash related to a yeast infection. a rash related to immobility.
C
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? Infection of the wound Herniation of the wound Dehiscence of the wound Evisceration of the viscera
C
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? Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.
C
The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? Contact the health care provider. Change the dressing. Document the findings. Notify the wound care nurse.
C
The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse uses wet-to-dry dressings continuously. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse packs the wound cavity tightly with dressing material.
C
The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad? 90°F to 99°F (32.2°C to 37.2°C) 100°F to 104°F (37.7°C to 40°C) 105°F to 109°F (40.5°C to 43°C) 110°F to 115°F (43.3°C to 46.1°C)
C
The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? "You will receive medication through this device." "Drainage will occur by gravity and capillary action." "It provides a way to remove drainage and blood from the surgical wound." "The bulb-like system will stay in place permanently after your mastectomy."
C
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? If there is contamination of dirt and debris The event leading up to the trauma Staging the wound for assessment The status of the client's tetanus immunization
D
A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? puncture laceration contusion avulsion
D
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 biosurgical debridement enzymatic debridement mechanical debridement
D
The registered nurse (RN) observes the licensed practical nurse (LPN) applying a topical gel to a client's surgical wound with her gloved finger during a dressing change. What instructions should the RN provide the LPN regarding this action? "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." "This procedure can be safely preformed using clean technique if care is taken not to touch the wound." "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."
D