Chapter 32 CP
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? I -Infection of the wound -Herniation of the wound -Dehiscence of the wound -Evisceration of the viscera
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.
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.
Keep the swab and the inside of the culture tube sterile. Explanation: The swab and the inside of the culture tube should be kept sterile. 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 a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? "I should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy." "I will put a layer of cloth between my skin and the ice pack." "I can let this stay on my ankle an hour at a time." TAKE ANOTHER QUIZ
"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 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."
"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. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.
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.
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. The other options might be appropriate but only after the client has been assessed.
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.
Clean the wound from the top to the bottom and from the center to outside. 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.
Which is not considered a skin appendage? -Hair -Connective tissue -Sebaceous gland -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.
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 As a stage II pressure injury As a stage III pressure injury As a stage IV pressure injury
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. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV.
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.
Stop removing staples and inform the surgeon Explanation: If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.
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? gauze transparent hydrocolloid bandage
TRANSPARENT The nurse should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. A hydrocolloid dressing helps keep the wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.
A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound? There is an infection present. The client has wound dehiscence. There is evidence of evisceration. The client has fistula formation.
The client has fistula formation. Explanation: A fistula is an abnormal tubelike passageway that forms from one organ to outside the body. There is no information that would lead to a suspicion that the wound is infected. Wound dehiscence would be indicated by separation of the wound and evisceration would be evidenced by protrusion of abdominal contents through the wound.
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 a gauze dressing precut halfway to fit around the IV line a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics
a transparent film
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
tertiary intention Explanation: Healing by tertiary intention occurs when a delay ensues between injury and wound closure. This type of healing also is referred to as delayed primary closure. It may happen when a deep wound is not sutured immediately or is purposely left open until there is no sign of infection, then closed with sutures. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the primary wound are approximated or lightly pulled together. Wounds with full-thickness tissue loss, such as deep lacerations, burns, and pressure injuries, have edges that do not readily approximate. They heal by secondary intention. The open wound gradually fills with granulation tissue.
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? "Dehiscence is not anything that you need to worry about." "Dehiscence is when a wound has partial or total separation of the wound layers." "Dehiscence is a total separation of the wound with protrusion of the viscera through it." "Dehiscence is the softening of tissue due to excessive moisture."
"Dehiscence is when a wound has partial or total separation of the wound layers." 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.
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 is characterized by oozing from the tissue covering the wound -A wound with drainage that is a beige color -A wound that requires wound cleaning and irrigation -A 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.
For which client would the application of a hydrocolloid dressing be most appropriate? -A client with a sunburn affecting his back and torso -A client who has a partial-thickness venous ulcer with moderate drainage -A client whose surgical incision dehisced and became infected -A client who has just undergone a cholecystectomy (gallbladder removal)
A client who has a partial-thickness venous ulcer with moderate drainage Explanation: Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; they are appropriate for partial- and full-thickness wounds with light to moderate drainage. A sunburn would not normally warrant this type of wound dressing and they are not used on infected wounds. Hydrocolloid dressings are not used on uncomplicated surgical incisions.
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? -Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown -Superficial, which may be pinkish or red with no blistering -May vary from brown or black to cherry red or pearly white; bullae may be present -A superficial partial-thickness burn, which can appear dry and leathery
Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Explanation: Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.
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 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.