EAQ 48 Skin integrity and wound assessment

Which patient may require a pulsatile high-pressure lavage for wound irrigation?

A patient who has a necrotic wound Pulsatile high-pressure lavage may be the irrigation method of choice for necrotic wounds. However, the high pressure is contraindicated for graft sites and wounds with exposed blood vessels, muscles, tendons, and/or bone.

Which action taken during wound irrigation is correct?

Allowing the solution to flow from the least to most contaminated area

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

What responsibilities can be delegated to nursing assistive personnel (NAP) during wound care? Select all that apply.

Applying an elastic bandage Correct 3 Reporting any movement restrictions of the patient

A patient reports pain in the ankle joint due to sprain. Which nursing intervention is beneficial to the patient?

Applying an elastic bandage An elastic bandage helps immobilize and supports healing of a sprained the ankle. Elastic webbing is used to secure dressings. An elastic pressure bandage is used to create pressure over a body part, for instance, to prevent bleeding. A stretch pressure bandage may be applied to reduce or prevent edema but not to immobilize and prevent pain from a sprain. Topics

Which tasks in applying an abdominal binder can be delegated to nursing assistive personnel (NAP)? Select all that apply.

Applying the abdominal binder itself Correct 3 Reporting wound drainage Correct 4 Removing the binder at specified intervals

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

Blanchable erythema Blanchable erythema is an early indication of pressure that resolves without tissue loss if the pressure is removed. Pallor or molting is a sign of persistent hypoxia. Dark red or purple discoloration may indicate potential damage to blood vessels and tissue. Nonblanchable erythema is a sign of a stage I pressure ulcer.

What color is sanguineous drainage on a patient's dressing?

Bright red

What equipment is required if wound drainage is present when applying an ace bandage?

Clean gloves

When cleaning a wound, which action is incorrect?

Cleaning from the surrounding skin to the site of incision

Before applying a bandage, which technique is appropriate for cleaning an incision or the area surrounding a drain?

Cleaning in the direction from an isolated drain site to the surrounding skin

What is assessed to determine which wound irrigation products will best promote new tissue growth?

Color of wound tissue

After asking for the patient's level of comfort using a scale of 0 to 10, how should the nurse order the steps in assessing the patient's pressure ulcer?

Correct 1. Determine if the patient has any allergies to topical agents. Correct 2. Review the order for topical agents or dressing and location. Correct 3. Describe the procedure to the patient, and remove the dressing. Correct 4. Note the color and percentage of tissue type present in the wound base. Correct 5. Measure the width and length of the ulcer. Correct 6. Measure the depth of undermining by using a cotton-tipped applicator. Correct 7. Inspect the periwound skin, checking for maceration, redness, or any denuded areas. Correct 8. Remove gloves and perform hand hygiene. Correct 9. Review the medical record to assess for any significant weight loss

A patient is hospitalized with a severe leg wound. The registered nurse is performing wound irrigation. Arrange the steps of this procedure in order.

Correct 1. Fill a 35-mL syringe with irrigation solution. Correct 2. Attach a 19-gauge angiocatheter. Correct 3. Hold the syringe tip 2.5 cm above the upper area of the wound. Correct 4. Flush the wound with continuous pressure. Correct 5. Repeat everything until a clear drain is obtained

Arrange the events that occur during the proliferative phase of wound healing in chronological order.

Correct 1. Synthesis of collagen from fibroblasts Correct 2. Mixing of collagen with granulation tissue Correct 3. Contraction of the wound Correct 4. Migration of the epithelial cells from the wound edges The proliferative phase of wound healing lasts 3 to 24 days. Fibroblasts produce collagen that provides a matrix for granulation. Then, the collagen mixes with the granulation tissue to form a matrix that supports reepithelialization. It also provides mechanical and structural support to a wound. The wound contracts during this process to reduce the area that requires healing. Finally, the epithelial cells migrate from the wound edges to resurface.

A nurse discusses the purposes of wound dressings with a nursing student. Which of the nursing student's statements indicates the need for further learning?

Correct4 "Dressings provide a dry environment to facilitate healing

The primary health care provider instructs the nurse to irrigate an infected wound that has a high concentration of bacteria. Which type of irrigating fluids will the nurse most likely use? Select all that apply.

Dakin's solution Correct 4 Hydrogen peroxide Correct 5 Povidone-iodine solution

A patient who has severe dehydration is admitted to the hospital and reports restlessness, inability to concentrate, dizziness, and difficulty breathing. What may be the cause of the patient's symptoms?

Decreased circulating blood volume

The nurse is teaching a group of patients about preventing respiratory problems. Which intervention should the nurse include in the teaching?

Discourage the patients from playing with pets.

The nurse is caring for a patient who has been diagnosed with pneumonia. The patient reports intermittent episodes of cough accompanied with thick yellow sputum. On auscultation, the nurse finds abnormal lung sounds (crackles) in the left base and both upper lobes. A chest x-ray reveals infiltrations in both upper lobes and the left lower lobe. Which instructions given by the nurse are appropriate for this patient? Select all that apply.

Drink good quantities of warm water." Correct 2 "Walk around as much as you can." 3 "Perform deep-breathing exercises once every 2 hours."

How can the nurse prevent maceration of tissue surrounding a wound?

Drying the wound edges with gauze

What must be assessed prior to the application of an abdominal binder? Select all that apply.

Effective coughing Ability for deep breathing

Which nursing action regarding bandages is beneficial for enhancing venous return?

Elevating the dependent extremities before applying the bandage

What is the function of pressure dressings when applied with an elastic bandage?

Eliminates the dead space in underlying tissues to allow healing

The nurse checks the distal circulation of a patient who has a bandage twice in an 8-hour period. Which part of the nursing process is this?

Evaluation

Which is required for wound irrigation?

Gauze dressing supplies

Which action done while irrigating a wound with a wide opening is incorrect?

Holding the syringe tip 1 cm above the upper end of the wound

The registered nurse and a nursing student are discussing evaluation of a patient after application of an elastic bandage. Which of the nursing student's statements indicate a need for further learning? Select all that apply.

I will remove the dressings in the morning." "I will assess the skin under the bandage every 12 hours

Which nursing intervention is appropriate when wound drainage increases?

Increase irrigation frequency

What step is a component of the planning phase for a patient who has impaired skin integrity?

Involve the patient and family in choosing interventions

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

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

What are the therapeutic benefits of heat application? Select all that apply.

It improves blood flow to injured body parts. Correct 5 It improves delivery of leukocytes to the wound site It promotes the movement of waste products

Which statements are true regarding pulsatile high-pressure lavage? Select all that apply.

It is used for necrotic wounds. Correct 4 The size of the wound determines the amount of irrigation to be done. Correct 5 It can be used for a patient who is on anticoagulant therapy

Which body parts should be dressed in a figure-eight manner?

Joints Figure-eight dressings are used to cover joints because they provide a snug fit and immobilization. Cylindrical body parts like the thighs, upper arms, and lower arms should be dressed in a spiral manner.

Which actions should the nurse perform on a patient who has a bandage only after receiving a health care provider's order? Select all that apply

Loosening the bandage if there are signs of circulatory impairment Correct 5 Removing the bandage if there are signs of circulatory impairment

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

Which action is inappropriate for maintaining an airtight seal in negative-pressure wound therapy?

Moistening the periwound area thoroughly

Which type of wound requires irrigation with pulsatile high-pressure lavage?

Necrotizing wound Pulsatile high-pressure lavage is the irrigation method of choice for necrotizing wounds. A draining wound can be cleaned with normal saline. A colonizing wound is irrigated with sodium hypochlorite solution, which is a cytotoxic fluid. Granulating wounds can be irrigated with normal saline

Which solution is used to clean a wound before obtaining a culture?

Nonbacteriostatic saline

Which nursing intervention is appropriate for a wound that does not appear to be healing?

Notifying the health care provider

A nurse is evaluating the circulation of a patient who has a bandage over a deep lower leg wound. What should the nurse check to assess circulation? Select all that apply.

Numbness Correct 5 Capillary refill The toes

Which patient is at risk for systemic infection if heat is applied as a form of therapy?

Patient with an abscessed tooth

Which action is inappropriate when applying an abdominal binder

Placing the patient in a prone position

Upon evaluation of a patient with an elastic bandage on his or her arm, which observations indicate impaired circulation? Select all that apply.

Pooling Correct 2 Reduced pulses Discoloration of the skin

What is the role of vitamin A in wound healing?

Promotes wound closure

Which are not benefits of binders and bandages over wound dressings? Select all that apply.

Promoting circulation Correct 2 Preventing infection

A patient's wound drainage appears thick and yellow. Which type of drainage is this considered?

Purulent

Which nursing action is appropriate when the skin under the elastic bandage breaks?

Reapply the bandage at a different area with less pressure The bandage should be reapplied at a different area with less pressure if the skin under the elastic bandage breaks. Assessing the pulse, palpating the extremity, and reapplying the bandage over the same area with less pressure are appropriate actions when the bandage has impaired circulation, not when it has broken the skin.

During an evaluation of a patient with elastic bandages, the nurse observes signs of impaired circulation in the surrounding area. What should be the nurse's priority action?

Release the bandage

The nurse observes edema and abrasions at the wound area under an elastic bandage. Which nursing action is the priority?

Removing the bandage

How are the irrigation procedures for cleaning a wound with a wide opening and a deep wound with a narrow opening similar?

Same gauge size of the angiocatheter

What must be assessed to decide the volume of irrigant necessary for cleaning the wound?

Size of the wound

What is characteristic of stage III pressure ulcers?

Slough may be present with slough, but it does not obscure the depth of tissue loss.

The registered nurse is overseeing a nursing student who is caring for a patient who has impaired circulation distal to an elastic bandage. Which of the practical nurse's actions needs correction?

Taking a wound culture

Which statements are true regarding the application of an abdominal binder? Select all that apply.

The far side should be fan-folded toward the midline of the binder. Correct 2 The binder can be secured with Velcro closure tabs. Correct 3 The patient should be instructed to roll toward the side rail during application

Identify the type of suture depicted in the image.

The image shows retention sutures, which are placed more deeply than skin sutures. Continuous sutures have a series of stitches, but they are not individually knotted. In intermittent sutures, each individual suture is made in the skin. A blanket suture is a continuous self-locking stitc

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

The ischium pressure ulcer site is just below the buttock on the upper thigh. The sole pressure ulcer site is found on the bottom of the foot. The sacrum pressure ulcer site is on the tailbone, or just above the gluteal area. The scapula pressure ulcer site is found on the shoulder blade.

Which statement is true regarding irrigation equipment used for cleaning wounds?

The volume of the irrigant should be higher than the volume of the wound

Which statements are true regarding use of an abdominal binder following surgery? Select all that apply.

They protect incisions during movement. Correct 4 They are secured with Velcro strips. Correct 5 They are effective in providing comfort during coughing.

What is the rationale behind applying an elastic bandage over an arterial puncture site?

To create pressure

When applying an abdominal binder, the nurse locates the symphysis pubis and costal margins. What is the purpose of this nursing action?

To ensure the binder is centered The nurse uses the symphysis pubis and costal margins as lower and upper landmarks for centering the supine patient over an abdominal binder when applying it. The binder itself supports the abdominal incision. Velcro strips are used to secure the binder once it has been centered. The patient can be rolled toward one side to place the binder under the patient.

Why should the nurse form a cuff on a waterproof bag and place it near the bed while performing wound irrigation?

To hold contaminated dressings to be discarded

Before irrigating a patient's wound, the nurse notes the number and types of drains present. What is the rationale behind this? Select all that apply.

To identify the type and number of the dressings required Facilitate safe dressing removal

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

Why will a nurse hold a syringe tip 2.5 cm above a wound with a wide opening during irrigation?

To prevent syringe contamination

When putting an elastic bandage on a patient who has a wound, the nurse applies additional rolls of gauze covering the entire skin surface. What is the rationale behind this nursing action?

To prevent wrinkling

What is the rationale for using a 19-gauge angiocatheter for irrigating a wound with a wide opening?

To provide ideal pressure for cleaning

Why would a nurse apply a binder over an abdominal incision?

To support the wound

Which nursing action while applying an elastic bandage is done to maintain uniform bandage tension?

Unrolling and slightly stretching the bandage

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

Unstageable

Which are used to secure an abdominal binder?

Velcro strips

Which nutrient is an antioxidant that promotes wound healing?

Vitamin C

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?

old drainage

A nurse is educating a patient about the role of nutrients in wound healing. Which statement will the nurse include?

protein facilitates collagen formation, and the recommended quantity is 1.25 to 1.5 g protein per kilogram of body weight."

What are the therapeutic benefits of using bandages over dressings? Select all that apply.

secures splints Correct 2 Prevents edema in the lower legs Secures dressings

The nurse is discussing home care wound irrigation with a patient and the caregiver. Which of the patient's statements indicates a need for further teaching?

"I can continue using normal saline solution if there are signs of infection."

A registered nurse and a nursing student are discussing elastic bandage application. Which of the nursing student's statements indicates a need for correction?

"I should not apply a bandage if there is an open wound."

Which statement made by the student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube?

"I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient.

The nursing instructor is discussing the Braden Scale for pressure ulcer development risk with a nursing student. Which of the student's statements is incorrect?

"The Braden Scale has shown sufficient predictive validity and accuracy for all patients.

The registered nurse is discussing wound irrigation with a nursing student. Which of the nursing student's statements indicates a need for further learning? Select all that apply.

"The wound should be irrigated with the syringe tip in the drainage site." Correct 5 "The pressure applied during irrigation can damage the healing wound tissue. "The syringe flushes the wound with constant high-pressure flow

A patient with chronic obstructive pulmonary disorder is trying to do diaphragmatic breathing exercises for the first time. The patient is sitting and feels uncomfortable doing the exercise. Which would be the most appropriate response by the nurse?

"You have to practice these exercises first in the supine position and then in the sitting position.

Arrange the steps for applying an abdominal binder in order.

.1. Place the patient in a supine position. 2. Fan-fold the far side of the binder toward the midline of the binder. 3. Help the patient roll toward the raised side rail 4. Place fan-folded ends of the binder under the patient 5. Adjust the binder so that the patient is centered over it. 6. Pull one end of the binder over center of patient's abdomen

The nurse is irrigating a deep wound with a small opening. In which order should the following actions be performed?

1. Fill the syringe, and attach it to the catheter. 2. Insert the tip of the catheter into the wound 3. Pull out the catheter about 1 cm. 4. Flush the wound using slow and continuous pressure 5. Insert the tip of the catheter into the wound 6. Observe for the presence of debris in the collection basin

Arrange the steps for preparing an ice bag in order.

1.Fill the bag with water, and check it for leaks. Correct 2. Fill two thirds of the bag with crushed ice. 3. Squeeze the bag's sides to release any air. Correct 4. Cover the bag with a flannel cover, towel, or pillowcase

What amount of protein per kilogram of body weight a day should the nurse recommend a patient consume to support wound healing?

3.5 to 4.5 g

How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing?

30-35 kcal

What amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing?

30-35 mL

What is required for a wound irrigation delivery system?

A 19-gauge angiocatheter