Chapter 48 Skin and Wounds

The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indicates a need for further learning?

Choosing a dressing that keeps the periwound moist

When cleaning a wound, which action is incorrect?

Cleaning from the surrounding skin to the site of incision

The registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning?

Collecting wound culture samples from old drainage

What is the role of vitamin A in wound healing?

Promotes wound closure

The nurse is teaching a group of nursing students about the role of nutrients in wound healing. Which statements are correct? Select all that apply.

Protein needs are increased and are essential for tissue repair and growth. Trace elements are required for epithelialization and collagen fiber linking. Calories provide the energy source needed for cellular activities involved in wound healing. A balanced intake of protein, fat, carbohydrates, vitamins, and minerals is critical to support wound healing.

Which factor increases the risk of wound infection?

Reduced local tissue defenses

What does the Braden Scale evaluate?

Risk factors that place the patient at risk for skin breakdown

Which type of ulcer can be dressed with a transparent or hydrocolloid dressing?

Stage I

Which statement regarding the skin is true?

The dermis and the inner layer of the skin provide tensile strength.

Which nutrient supports healing by promoting wound closure?

Vitamin A

The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which patients would be at increased risk of wound dehiscence? Select all that apply.

A malnourished patient An obese patient A patient with wound infection

The nurse works in a long-term care unit. Which patients would be at high risk of developing pressure ulcers? Select all that apply.

A patient with a spinal cord injury A comatose patient A patient with urinary incontinence An immobile patient with excessive wound drainage

The nurse is preparing a care plan for a patient who has a pressure ulcer on the coccyx. Which part of the plan is included to provide comfort to the patient?

Applying a moisture barrier ointment over the ulcer

A patient who has an acute wound due to trauma is admitted to the emergency unit. Which nursing action for wound care is the priority in this situation?

Applying a sterile dressing as per the health care provider's order

Under the supervision of the registered nurse, a nursing student is providing negative-pressure wound therapy to a patient who has a wound near the knee joint. Which nursing action indicates the need for further learning?

Applying adhesive remover at the affected site before the dressing

A patient presents to the emergency department with severe injuries. The nurse notices that the wound on the abdomen is so deep that the liver has been eviscerated. What prompt actions does the nurse take in such a case? Select all that apply.

Assess the patient for symptoms of shock. Contact the surgical team for emergency surgery. Place sterile gauzed soaked in saline over the wound.

What terms are used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part? Select all that apply.

Bedsore Pressure sore Pressure ulcer Decubitus ulcer

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated?

Blanchable erythema

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

A senior nurse is teaching a group of students to assess skin changes related to development of pressure ulcers. What should the students keep in mind when assessing dark-skinned patients? Select all that apply.

Blanching is not a conclusive sign in these patients. Differentiate skin color changes with reference to baseline skin tone. Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of patients with dark skin.

After surgery, the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.

The nurse is caring for older adult patients in a nursing home. The nurse understands that older adults are susceptible to development of pressure ulcers and other wounds. What makes older adults more vulnerable to developing pressure ulcers? Select all that apply.

Diminished inflammatory response Loss of collagen and thinning of muscles

While assessing a patient with major wounds, the nurse finds that the patient has a zinc deficiency. Which foods should be included in the patient's diet plan? Select all that apply.

Drainage for more than 3 days after closure

Under the supervision of the registered nurse, the nursing student is repositioning a patient to reduce the risk of pressure ulcers. Which nursing action indicates a need for further learning?

Encouraging the patient to sit on a donut-shaped cushion

The nurse notices an increased amount of red-colored fluid from the drain in a postoperative patient who had undergone abdominal surgery 2 days ago. The nurse inspects the incision site and notices some swelling and warmth over the incision. The patient is otherwise afebrile and has stable vital signs. Of what are these findings indicative?

Hemorrhage

A patient who has a stage III pressure ulcer develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. What will the nurse suspect is occurring in the patient?

Infection

A patient with limited mobility develops a Stage III sacral pressure ulcer. Which nursing interventions are appropriate for reducing the risk of wound infection in this patient? Select all that apply.

Irrigating and cleansing the wound with saline twice a day Packing the open wound with antibiotic solution-moistened gauz

Which pressure ulcer site is found immediately distal to the buttock?

Ischium

A patient is admitted with a stage II pressure ulcer. What characteristics of a pressure ulcer is the nurse likely to find during a wound assessment?

It has a reddish pink wound bed without slough.

The patient has a stage III pressure ulcer. Which findings are characteristic of this type of pressure ulcer? Select all that apply.

It has full-thickness tissue loss. The subcutaneous fat may be visible. The bone, tendon, or muscle is not exposed.

The patient has a stage III pressure ulcer. Which findings are characteristic of this type of pressure ulcer? Select all that apply.

It has full-thickness tissue loss. The subcutaneous fat may be visible. The bone, tendon, or muscle is not exposed.

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility?

Lateral rotation surface

Which blood cells are known as garbage cells?

Macrophages

In a supine position, which site is not at risk for a pressure ulcer?

Medial knee

According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer?

Poor nutrition

The edges of a patient's appendectomy incision are approximated, and no drainage is noted. Which type of healing should be applied?

Primary intention

The nurse understands that a protein deficiency can adversely affect wound healing. What parameters should be measured to determine this deficiency in the patient? Select all that apply.

Serum albumin Serum transferrin Serum prealbumin

Which type of pressure ulcer is noted to have intact skin and may include changes in skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

Stage I

Which stage of the pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough?

Stage II

A long-term care facility encourages nurses to assess patients at risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. What tool is the facility using for risk assessment of pressure ulcer development?

The Braden Scale

The nurse is attending to a patient who is bedridden after a prolonged illness. The patient has darkly pigmented skin, which makes it difficult for the nurse to detect pressure ulcers. What characteristics will alert the nurse to the possibility the patient may develop pressure ulcers? Select all that apply.

The color remains unchanged when pressure is applied. The circumscribed area of intact skin may be warm to touch. Inflammation may be detected when compared with the surrounding skin.

The nurse assesses an elderly patient admitted to the hospital after a fall. What assessment findings could place the patient at risk for developing pressure ulcers? Select all that apply.

The patient has urinary incontinence. The patient is immobilized due to a leg fracture. The patient has impaired sensory perception

A 36-year-old man is admitted to the hospital following a motor vehicle accident. He has sustained multiple injuries on the forehead, right elbow, and left knee. An x-ray of the knee shows a hairline fracture of the left patella. When giving cold therapy to this patient, what should the nurse keep in mind? Select all that apply.

The patient should be informed that a change in sensation is normal. The patient should be within the reach of the call light. The position of the patient should allow him to move away from the cold source.

A dark-skinned hospitalized patient is bedridden. While examining the patient, which characteristics will determine that the patient has developed a pressure ulcer? Select all that apply.

The skin color remains unchanged on application of pressure. The localized area of the skin appears purple.

The nurse assesses a patient's abdominal wound and finds that the wound is in the proliferative phase of healing. Which changes in the wound might have led the nurse to this conclusion? Select all that apply.

The wound is filled with granulation tissue. The wound contracts to reduce the area that requires healing. There is reepithelialization of the wound surface.

The nurse is preparing a diet plan for a patient admitted to a wound care unit. After the nurse explains the diet plan to the patient, the patient asks the reason for an increase in the intake of citrus fruits. What should the nurse explain to the patient? Select all that apply.

They have antioxidant properties. They help in collagen synthesis. They provide fuel for cell energy.

While caring for a patient in the postsurgical unit, the nurse palpates the area around the surgical wound and asks the patient if there is tenderness. What is the rationale behind this nursing action?

To assess for the risk of periwound edema

A patient with an abdominal wound from a motor vehicle accident comes into the emergency room with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. What is the rationale for this nursing action?

To prevent infection

What characteristics differentiate a friction injury from a shear injury? Select all that apply.

Type of force Involvement of tissue Presentation of the injury

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?

Unstageable

While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer?

Unstageable

The nurse understands that the nutritional status of a patient is an important factor in wound healing. Which vitamins should be provided to the patient to promote wound healing? Select all that apply.

Vitamin A Vitamin C

Which nutrient is an antioxidant that promotes wound healing?

Vitamin C

The nurse is performing an admission assessment on a patient who is paralyzed due to a stroke. The nurse notices a redness of the skin in the sacral area. What characteristics of the skin and surrounding tissues help the nurse to classify the wound as a stage I pressure ulcer? Select all that apply.

Warm, edematous skin The area is cooler than the adjacent tissue. It has localized nonblanchable erythema.