Chapter 32: Skin Integrity and Wound Care

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?

Implement a 2-hour repositioning schedule

The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?

oblique

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?

secondary intention

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

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed

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."

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.

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

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 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 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.

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

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

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 No finger numbness or tingling

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?

Fish

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

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

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound?

an alginate dressing

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?

Zinc

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

An infant's skin and mucous membranes are easily injured and at risk for infection.

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

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.

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

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

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?

adhesive strips with eyelets

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

an obese woman with a history of type 1 diabetes

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 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 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."

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."

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 client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them?

Apply moist saline compresses to loosen crusts before attempting to remove the staples.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

Apply saline solution-moistened gauze over the protruding area.

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

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.

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.

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.

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

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

dehiscence.

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

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?

hydrocolloid

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

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