Chapter 32: Skin Integrity and Wound Care pt. 2

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? A) An infant's skin and mucous membranes are easily injured or at risk for an infection. B) In children younger than 2 years, the skin is thicker and stonger than in adults. C)A child's skin becomes less resistant to injury and infection as the child grows. D) An individuals skin changes little over the lip span.

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? A) foul-smelling drainage that is grayish in color B) copious drainage that is blood-tinged C) large amounts of drainage that is clear and watery and has no smell D) small amount of drainage that appears to be mostly fresh blood

A

A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn? A) moist with blisters, which may be pink, red, pale ivory, or light yellow-brown B) pinkish or red with no blistering C) from brown or black to cherry red or pearly white; bullae may be present D) dry and leathery

A

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? A) transparent B) gauze C) hydrocolloid D) adhesive strips with eyelets

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? A) Pasta salad B) Fish C) Banana D) Green beans

B

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? A) "The condition is hard to cure." B) "You will likely experience periods of increased skin outbreaks and periods of remissions." C) "You will have this disease for life." D) "Your personal health habits will dictate how well you handle this condition."

B

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? A) The nurse uses a safety pin to attach the pad to the bedding. B) The nurse covers the heating pad with a heavy blanket. C) The nurse places the heating pad under the clients neck. D) The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

D

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? A) If there is contamination of dirt and debris B) The even leading up to the trauma C) Staging the wound for assessment D) The status of the client's tetanus immunization

D

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? A) As a stage I pressure injury B) As a stage II pressure injury C) As a stage III pressure injury D) As a stage IV pressure injury

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? A) Discontinue the therapy and assess the client. B) Notify the health care provider of the findings. C) Document the findings in the client's medical record. D) Gently rub and massage the area to warm it up.

A

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? A) "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." B) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." C) "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." D) "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 cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? A) Use clean technique to clean the wound. B) Clean the wound in a circular pattern, beginning on the perimeter or the wound. C) Clean the wound from the top to the bottom and from the center to outside. D) Once the wound is cleansed, gently dry the wound bed with an absorbent cloth

C

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document? A) serous B) sanguineous C) serosanguineous D) purulent

C

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? A) Assess the client's wound and vital signs. B) Administer the prescribed analgesic. C) Notify the health care provider of the pain. D) Document the pain and vital signs.

A

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? A) removing dead or infected tissue to promote wound healing B) stimulating the wound bed to promote the growth of granulation tissue C) removing purulent drainage from the wound bed in order to accurately assess it D) removing excess drainage and wet tissue to prevent maceration of surrounding skin

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) a sterile, flexible applicator moistened with saline B) a small plastic ruler C) a sterile tongue blade lubricated with water soluble gel D) an otic curette

A

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

C

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? A) avulsion B) abrasion C) incision D) laceration

C

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? A) Cleanse the wound after obtaining the wound culture. B) Stroke the culture swab on surrounding skin first. C) Utilize the culture swab and obtain cultures from multiple sites. D) Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

D

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? A) Infection of the wound B) Herniation of the wound C) Dehiscence of the wound D) Evisceration of the viscera

C