Chapter 28: Wound Care

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care?

An older adult

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

Apply lotions?

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated, WBCs move into the wound.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care?

Cleanse with a new gauze for each stroke.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

Corticosteroids

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

Decubitus ulcer

The nurse 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

The nurse is caring for a 7-year-old who suddenly developed difficulty hearing out of the left ear. Which nursing action is appropriate?

Perform a thorough inspection of the ear.

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

Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change.

A group of nursing students is reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which as healing by primary intention?

Surgical incision

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

There is an unintentional separation of the wound.

In consultation with a wound care nurse, a nurse has included wound irrigation in the nursing care plan of a client. What characteristic of the client's wound would justify the use of irrigation during the wound care regimen?

There is debris on the client's wound bed but granulation has begun to form.

What observation should the nurse note about a client's open wound if the wound is healing by the third intention?

Wound edges are widely separated and brought together with closure material.

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record?

a separation of skin and tissue in which the edges are torn and irregular

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 in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

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

foul-smelling drainage that is grayish in color

The nurse has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn?

gauze

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

hydrocolloid dressings

A skin infection caused by beta-hemolytic streptococci common in children is:

impetigo.

In the older adult client, wrinkling is related to:

loss of elasticity.

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

nonblanchable redness

A child is brought to the clinic by his mother. The mother states he has been at Boy Scout camp. The child has a rash on his face, arms, and legs. The child states it itches severely. The child has probably come in contact with:

poison ivy.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the bandage?

supports the area around the wound

The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

Assess the wound for active bleeding.

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication?

Evisceration

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?

Montgomery straps

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

Notify the physician and prepare for surgery.

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

Transparent

A 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 ulcer?

Use pillows

The nurse should use extreme caution when applying heat therapy to which of the following clients?

a client who is unconscious

What is the most accurate definition of a wound?

a disruption in normal skin and tissue integrity

A client's risk for the development of a pressure ulcer is most likely due to which lab result?

albumin 2.5 mg/dL

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

A client has developed blisters around the tape that secures the dressing. What nursing action would be appropriate to prevent further damage to the tissues?

apply the dressing with a binder.

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

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and:

covering the wound area with sterile towels moistened with sterile 0.9% saline.

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar.

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

primary intention.

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"It provides a way to remove drainage and blood from the surgical wound."

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

"Do not douche 24-48 hours before the procedure."

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."

The nurse is caring for a client with a knee sprain. Which client statement regarding use of an ice pack indicates that nursing teaching has been effective?

"I will put a washcloth between my knee and the ice pack."

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?

"I will restrict my diet to fats and carbohydrates."

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."

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include?

"It is important to keep your sutured incision clean."

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.

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other."

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate?

"You will likely experience periods of increased skin outbreaks and periods of remissions.

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."

The physician has prescribed heat therapy for a client's leg wound. The nurse is preparing the client for the heat therapy and informs the client that he will have warmed compresses on the leg wound for:

20 to 30 minutes.

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

A Penrose drain promotes drainage passively into a dressing.

A nurse working in long-term care is assessing residents at risk for the development of a pressure ulcer. Which one would be most at risk?

A client 86 years of age who is bedfast

A nurse is caring for a client who has a 6-cm × 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 best to be ordered by the primary care provider?

Alginate

Dehiscence is the softening of tissue due to excessive moisture.

False

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

A nurse at an extended care facility is conducting an in-service for care staff on the prevention of pressure ulcers. Which preventive measures should the nurse recommend?

Apply pads to the bony prominences of residents who have impaired mobility.

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

Assist in moving to prevent strain on the suture line.

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?

Body image is of little importance to the traditional French cultural beliefs.

The nurse is performing an admission assessment on a client being admitted to a long-term care facility. The nurse notes the client has a history of psoriasis. Which locations on the body is the nurse most likely to find manifestations consistent with the condition? Select all that apply.

Elbows Knees Soles of the feet

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings?

Implement a turning schedule every 2 hours.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

Local capillary pressure must be lower than external pressure.

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?

Mechanical debridement

A nurse is preparing to change the dressing on an elderly client's sacral wound that developed after a prolonged period of immobility prior to admission. Which action should the nurse perform while performing an aseptic change of this client's dressing?

Perform hand washing before the dressing change and after removing the existing dressing.

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

Pertulent

A nurse is assessing a client's diabetic ulcer and notes the color of the wound's base. Which color would the nurse interpret as indicating a healthy wound with adequate circulation?

Pink

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Proliferation phase

The nurse is instructing mothers of toddlers on the care of skin and the prevention of injury. The nurse should include which of the following educational interventions?

Protect from burns by covering electric outlets, and have a safe zone.

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the client's chance of skin breakdown?

Reposition the client on a regular basis.

Which processes are responsible for restoring integrity of the skin and damaged tissues when caring for a client with an open wound? Select all that apply.

Resolution Regeneration Scar formation

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?

Risk for Infection

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 describes this?

Second Intention

The nurse is discussing home remedies for insect bites with a group of college students. The nurse correctly includes which remedy in the presentation?

Secondary intention

The nurse is using the Braden Scale to deterine a client's risk factor for developing pressure ulcers. What criteria will the nurse assess? Select all that apply.

Sensory perception Nutrition Ability Friction

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

Serosanguineous

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?

Soak in a warm bath for drainage

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?

Stage III

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues. How would she document this wound?

Stage III pressure ulcer

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

Support the client from sliding in bed

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?

infection

The nurse educator on a hospital's acute medical unit has created a document encouraging nurses to use cold applications when appropriate to clients' plans of care. What benefits of cold application should the educator cite?

prevention of swelling

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

A client comes to the emergency department after falling off of a skateboard onto the sidewalk. Which assessment data, consistent with an abrasion, would the nurse expect to see?

scraping off of surface layers of skin

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

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force

A nursing student visits a nursing instructor's office and the instructor states, "Gina, are you tanning in a tanning booth?" The nursing student says yes. The nursing instructor's best response would be to instruct her on:

the rate of cancer from exposure to sun and tanning beds.

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

to apply sunscreen when exposed to ultraviolet rays.