FN - Unit 2 - Chapter 33: Skin Integrity and Wound Care

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The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? "You will receive medication through this device." "Drainage will occur by gravity and capillary action." "It provides a way to remove drainage and blood from the surgical wound." "The bulb-like system will stay in place permanently after your mastectomy."

"It provides a way to remove drainage and blood from the surgical wound." The bulb-like drain allows the removal of blood and drainage from the surgical site. Drainage in this system is aided by low suction, not by gravity or capillary action. It does not provide a route for medication administration, nor does it stay attached permanently.

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. Clean the wound from top to bottom. Clean from the outside of the wound to the center. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps. Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps.

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy. Which interventions should the nurse follow to apply the T-binder? (Select all that apply.) Fasten the crossbar around the waist. Pass the tails through the client's legs. Clean the insertion in a circular manner. Pin the tails to the belt of the T-binder. Place the precut drain sponge on the anus.

Fasten the crossbar around the waist. Pass the tails through the client's legs. Pin the tails to the belt of the T-binder When applying a T-binder to secure a dressing to the anus of a client who has undergone hemorrhoidectomy for piles, the nurse fastens the crossbar of the T around the waist. Then the nurse passes the single or double tails between the client's legs and pins the tails to the belt. Adhesive sanitary napkins worn inside briefs are an alternative to a T-binder for stabilizing absorbent materials. When managing a closed drain, the nurse cleans the insertion in a circular manner. After cleansing, the nurse places a precut drain sponge or gauze, which is open to its center, around the base of the drain.

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

Broken left ankle Abrasions Soft tissue damage Concussion Bruising Skateboard related injuries that the nurse needs to assess for are a concussion and other brain injuries, broken bones, soft tissue injuries, and skin abrasions, cuts, and bruises. Symptoms of a concussion are dizziness, headaches, visual changes, loss of memory, slowed speech, and sensitivity to noise. An abrasion involves stripping of layers on the skin's surface. Soft tissue injuries include damage to the muscles, tendons, and ligaments. Dehydration can cause headaches and dizziness; however, since the client injured oneself while skateboarding a concussion should be suspected and assessed for. Because the client reported sliding on the sidewalk, the client should also be assessed for skin abrasions.

A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options. Clean the incision using the wound cleanser and gauze. Apply adhesive closure strips. Using the scissors, cut one side of the suture below the knot, close to the skin. Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. Remove every other suture to be sure the wound edges are healed. Grasp the knot with the forceps and pull the cut suture through the skin.

Clean the incision using the wound cleanser and gauze. Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. Using the scissors, cut one side of the suture below the knot, close to the skin. Grasp the knot with the forceps and pull the cut suture through the skin. Remove every other suture to be sure the wound edges are healed. Apply adhesive closure strips. Incision cleaning prevents the spread of microorganisms and contamination of the wound. Raising the suture knot prevents accidental injury to the wound or skin when cutting. Pulling the cut suture through the skin helps reduce the risk for contamination of the incision area and resulting infection. Removing every other suture allows for inspection of the wound, while leaving an adequate number of sutures in place to promote continued healing if the edges are not totally approximated. Adhesive wound closure strips provide additional support to the wound as it continues to heal.

A nurse on a medical-surgical unit is completing the admission assessment on a 38-year-old client. The client is feeble and unable to get out of bed and at times they slide down and require assistance for repositioning. They respond to verbal commands, but cannot accurately express discomfort and have no sensation in the left lower extremity. The client is only able to make frequent, but slight, changes in extremity position. The client has no control over their bowel or bladder and subsequently requires linen changes at least twice per shift. When fed, the client generally eats 50% or less of each meal. Using the Braden Scale, identify the appropriate score and description associated with the client's risk factors. Sensory Perception - Completely Limited - 1, Very Limited - 2, Slightly Limited, No impairment - 4 Moisture - Constantly Moist - 1, Very Moist - 2, Occasionally Moist, Rarely Moist - 4 Mobility - Completely Immobile - 1, Very Limited - 2, Slightly Limited - 3, No Limitation - 4

Sensory Perception - Slightly Limited Moisture - Constantly Moist - 1 Mobility - Slightly Limited - 3 The client is considered to have slighlty limited sensory perception, because the client cannot accurately express discomfort and dowa not have the ability to feel pain in one extremity, the left leg. The client is scored as constantly moist, because the client requires frequent linen changes of more than once per shift and is completely incontinent of bowel and bladder, which increases the amount of time the skin is moist. The client is considered slightly immobile, because, although slight, the client is able to frequently move extremities independently. The friction and shear of the client are a potential problem as evidenced by a feebleness and occasional sliding down in the bed. Completely limited sensory perception is described as unresponsive to or the inability to feel pain. Very limited would be scored if the client is responsive only to pain and demonstrates pain by moaning or groaning. No impairment would be assessed if the client has no sensory deficits. A description of very moist would be assessed if the client's skin was often moist and required linen changes only once per shift. The description of occasionally moist would apply if the linen needed changed once per day and was only occasionally moist. Rarely moist is associated with dry skin and routine linen changes. When assessing mobility, completely immobile is associated with the inability to make any movements or position changes independently. Very limited means the client can make slight position changes occasionally but these are infrequent and insignificant. No limitation means the client can make frequent and major position changes independently. When assessing friction and shear, the nurse would note a problem if the cilent required extensive assist with positioning and complete lifting from the bed surface is not possible. This client frequently slides down in the bed. A client with no apparent friction or shearing problem does not slide down in the bed and has sufficient strength to lift up when repositioning themselves.

A client with anorexia nervosa has developed a pressure injury on the sacrum. Which laboratory result would indicate the client is at nutritional risk? Albumin level of 3.5 mg/dL Total lymphocyte count of 1,000/mm3 Body weight decrease of 3% Arm muscle circumference 90% of standard

Total lymphocyte count of 1,000/mm3 The following laboratory criteria indicate that a client is nutritionally at risk for development of a pressure injury: albumin level <3.2 mg/dL (normal, 3.4-5.4 mg/dL), prealbumin <15 mg/dL (normal 19-38 mg/dL), body weight decrease of 5% over 30 days or 10% over 180 days. Additional laboratory tests to consider in clients at risk for or presenting with pressure injuries include: total lymphocyte count <1,000/mm3 (normal, 1,500- 4,000/mm3), hemoglobin A1C >6.5% (normal <6%), glucose >126 mg/dL (fasting normal glucose <110 mg/dL).

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? Vitamin A Vitamin B12 Zinc Magnesium

Zinc Adequate intake of iron, copper, and zinc is important to prevent abnormal pigmentation and changes in nails and hair.

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? transparent adhesive strips with eyelets gauze hydrocolloid

adhesive strips with eyelets Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Transparent dressings are used to protect intravenous insertion sites. Hydrocolloid dressings are used to used keep a wound moist. Gauze dressings absorb blood or drainage; however, they are not suited to a large wound.

A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider? alginate hydrogel hydrocolloid transparent

alginate Alginates are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue. Hydrogels are used with dry wounds or wounds with minimal drainage. Hydrocolloids are used with light to moderate drainage in wounds with necrosis or slough. Transparent dressings are used with wounds having minimal drainage, small size, and partial thickness.

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 transparent film a hydrogel dressing an antimicrobial dressing

an alginate dressing Alginate dressings contain alginic acid from brown seaweed. Covered in calcium-sodium salts, they absorb exudate, maintain a moist wound environment, and facilitate autolytic debridement. A secondary dressing is required to secure them. Transparent film allows frequent assessment of the site but provides a barrier. A hydrogel dressing comprises an 80%-99% water base and is used with partial- and full-thickness wounds. An antimicrobial dressing has an antibiotic that reduces bacterial growth.

The nurse in the postanesthesia care unit (PACU) is assessing a new client who has just undergone abdominal exploratory laparotomy. Which response should the nurse prioritize after noting the SaO2 is 95% (0.95), blood pressure is 128/80 mm Hg, cardiac monitor is showing rare premature atrial contractions (PAC), and drainage on abdominal dressing is approximately 5 cm × 3 cm of pinkish drainage along the lower edge of the dressing? apply additional dressing, especially over the lower edge where drainage is occurring record full electrocardiogram (ECG) and notify health care provider provide oxygen via nasal cannula notify health care provider of overall condition of client

apply additional dressing, especially over the lower edge where drainage is occurring The health care provider will usually perform the initial dressing change after surgery; however, the nurse can reinforce the dressing by adding additional layers. The nurse would need to monitor the drainage and notify the health care provider if the drainage changes to red. The nurse would apply oxygen if prescribed by the health care provider. The reading of 95% (0.95) is within normal limits. A rare PAC is not uncommon and would not be reason to obtain a full ECG, especially if just out of surgery and no other signs or symptoms are currently noted. The nurse will document the assessment and report to the health care provider as per the facility's policies.

A client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues? applying tape to the side of the blisters using paper tape on the blisters applying the dressing with a binder applying skin barrier to protect the skin

applying the dressing with a binder Bandages, binders, and stretch nets also can be used to hold gauze dressings in place and will prevent further damage to the tissues.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Allow the wound and intestinal contents to remain open to air. Apply saline solution-moistened gauze over the protruding area. Pack the wound with gauze pads and a dry sterile dressing. Inform the client that this is an expected occurrence and not to worry.

Apply saline solution-moistened gauze over the protruding area. The first thing the nurse will do is cover the protruding intestine with a saline solution-moistened gauze. The nurse will then notify the health care provider of wound evisceration. If the protruding intestine is left open to the air, it may cause drying of the fragile tissue and necrosis to the area. The nurse should not pack anything into the wound since foreign body retention may cause complications at a later time if the gauze is not recovered. The occurrence of wound evisceration is not an expected finding and may be serious depending upon whether the protruding area is viable.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Desiccation Maceration Necrosis Evisceration

Desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

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 Superficial contusion accompanied by pruritus Diffuse fungal infection accompanied by pruritus Superficial abscess accompanied by pruritus

Diffuse dermatitis accompanied by pruritus The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching. A contusion is a closed wound with bleeding in underlying tissues from a blunt blow. Fungal infections do not cause a rash or itching. An abscess is a localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed.

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 Decreased radial pulse Cyanosis No finger numbness or tingling

Fingers with quick capillary refill Warm hand No finger numbness or tingling The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers. Cyanosis, pallor, coolness, numbness, tingling, swelling, or absent or diminished pulse are signs that circulation may be decreased or that nerve function is impaired.

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? Pasta salad Fish Banana Green beans

Fish To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

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. Use the same swab for both wound sites. Touch the swab to the intact skin at the wound edges. Tap the outside of the culture tube with the swab before placing it in the tube.

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. The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination.

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 prior to collecting the culture.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture. The swab and the inside of the culture tube should be kept sterile prior to the procedure. 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 an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help detect the potential for pressure injury? Select all that apply. Stages of pressure injuries Nutritional status Mental status Skin moisture Sensory perception

Nutritional status Mental status Skin moisture Sensory perception The client has blood clots that could potentially travel to the lungs (thromboembolism), so the client needs to be on strict bed rest until treated for the condition and determined safe to ambulate. Stages of pressure injuries are used after there is a break in the skin's integrity, and the nurse is examining the client for potential risks for developing a pressure injury in this case. Nutritional status is important to assess to determine if skin has adequate nutrients to replace damaged or dead cells daily. In older adults, the first clue of an infection—fluid and electrolyte imbalance—is often a change in the mental status, and all these factors can influence the client not adequately moving in bed and increase pressure on the bony prominences. Skin moisture needs to be assessed because excessively dry or moist skin will break down easier than skin with a normal amount of moisture. Sensory perception is important to assess because if the client cannot feel light touch or painful stimuli, the client may not recognize lying in one position too long, which leads to increased pressure on tissues and damage to the skin.

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? White Red Blue-grey Yellow

Red Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? Reduce the time interval between dressing changes. Assure that the packing material is completely saturated when placed in the wound. Use less packing material. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.

Reduce the time interval between dressing changes. Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

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 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 nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? Epidermis Dermis Subcutaneous tissue Muscle layer

Subcutaneous tissue The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Tearing of the skin and tissue with some type of instrument; tissue not aligned Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of a structure from its normal position Puncture of the skin

Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? Scarring, sutures, and wound care Tetanus, infection, wound care, and pain control Prevention of recurring infection, ability to work, and wound care Tetanus, being able to walk, and scarring

Tetanus, infection, wound care, and pain control Chances are the client knows that stepping on a nail could lead to a serious complication or illness, even if the client cannot remember or does not know about tetanus or infections. How to care for the wound is usually something clients will want to know before being discharged. The client in this scenario is reporting pain, so pain control will be one of the concerns. It is unlikely that the client will be worried about scarring on the bottom of the foot or sutures due to it being a puncture. The client is still walking, although in pain and with a limp, it would be unlikely the client would be concerned about being able to walk. More than likely, the client has already figured out the injury may not have occurred or would not be as bad had he or she been wearing shoes, so the nurse would not anticipate the need for preventative education.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse uses wet-to-dry dressings continuously. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse packs the wound cavity tightly with dressing material.

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? The nurse elevates the foot of the bed. The nurse uses a ring cushion to protect reddened areas from additional pressure. The nurse increases the amount of time the head of the bed is elevated. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible.

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 a client who lifts himself up on the elbows a client who lies on wrinkled sheets a client who must remain on the back for long periods of time

a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure injury from shearing forces would be a client sitting in a chair who slides down.

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 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.

The client has a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen. Which nursing concern will the nurse identify for this client's care plan? altered skin integrity due to open wound pain due to wound sustained by knife knowledge deficiency regarding wound care related to laceration infection risk due to wound

altered skin integrity due to open wound Altered skin integrity best describes the minor laceration. Although the other nursing concerns of pain, knowledge deficiency, and infection risk are possible as a result of the laceration, there is no indication in the scenario that they are the case.

Which client(s) is considered at risk for skin alterations? Select all that apply. an adolescent with multiple body piercings a client in a monogamous same-sex relationship a client receiving radiation therapy a client undergoing cardiac monitoring a client with diabetes

an adolescent with multiple body piercings a client receiving radiation therapy a client with diabetes Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a sexual relationship with multiple gay male partners would also place a client at risk for HIV and skin alterations, but this client is in a monogamous relationship. Cardiac monitoring does not place a client at risk for skin alterations.

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? puncture laceration contusion avulsion

avulsion An avulsion involves the stripping away of large areas of tissue, leaving cartilage and bone exposed. Therefore the nurse will document this assessment finding as an avulsion. A puncture is an opening of the skin caused by a narrow, sharp, pointed object. A laceration is the separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore the nurse would not document the finding as a puncture, laceration, or contusion.

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication? fistula dehiscence hemorrhage evisceration

evisceration Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

The nurse is preparing a discharge plan for an older adult client who recently underwent a hernia repair. Which action should the nurse include in the care plan to assist with this client's recovery? refer the client to a local group which provides home-delivered meals encourage the client to spend time at an assisted living facility before returning home provide neighbors with proper education to provide care inspect the home for potential safety issues

refer the client to a local group which provides home-delivered meals Several factors are known to delay healing in older adults related to age-related changes. One of those is inadequate nutrition, which can be related to poor appetite or physical or economic barriers. Referring the client to a local community agency which provides home-delivered meals would be an option to assist with this. It would be unethical for the nurse to try to talk the client into doing something not necessary or wanted. The nurse should function as an advocate, not insist the client follow the nurse's opinion. The nurse should only include neighbors if the client indicates this is desired. Including the neighbors without the consent of the client would be a breach of confidentiality. The nurse may refer the client for visits from a home health nurse who would be the one to conduct a safety inspection.

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? primary intention maturation secondary intention tertiary intention

secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound? suspected deep tissue injury stage II wound stage III pressure injury unstageable wound

suspected deep tissue injury A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial-thickness loss of dermis that often presents as an open blister. A stage III pressure injury is a full-thickness tissue loss in which subcutaneous tissue is visible. An unstageable wound is covered by slough or eschar. The depth of the wound is unknown because of this covering.

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad? 90°F to 99°F (32.2°C to 37.2°C) 100°F to 104°F (37.7°C to 40°C) 105°F to 109°F (40.5°C to 43°C) 110°F to 115°F (43.3°C to 46.1°C)

105°F to 109°F (40.5°C to 43°C) The nurse should set the external heating pad in the 105°F to 109°F (40.5°C to 43°C) range, which is physiologically effective and comfortable for the client. Lower temperatures are not as effective, and higher temperatures may cause damage to the underlying skin and tissues.

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 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.

What should the nurse assess before application of sitz bath therapy? Select all that apply. Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void Client's serum sodium levels

Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void Before application of sitz bath therapy, the nurse should assess the client's ability to ambulate to the bathroom; ability to sit for 15 to 20 minutes; appearance of the perineal/rectal area for swelling, drainage, tenderness; and the client's bladder fullness and need to void. Electrolyte levels are not affected by sitz bath therapy.

The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. Fill the bowl of the sitz bath about halfway full with tepid to warm water. Insert tubing into the infusion port of the sitz bath. Slowly unclamp the tubing and allow the sitz bath to fill. Ensure that the call bell is within reach. Hang the bag of tepid to warm water at the client's chest height on an IV pole. Have the client soak for about 50 to 60 minutes.

Fill the bowl of the sitz bath about halfway full with tepid to warm water. Insert tubing into the infusion port of the sitz bath. Slowly unclamp the tubing and allow the sitz bath to fill. Ensure that the call bell is within reach. The nurse should fill the sitz bath about halfway full with tepid to warm water, fill a bag with the same temperature water, insert the tubing from the bag into the infusion port of the sitz bath, and slowly unclamp the tubing and allow the sitz bath to fill completely. Tepid water can promote relaxation and help with edema; warm water can help with circulation. Filling the sitz bath ensures that the tissue is submerged in water. The call bell should be placed within reach because the client may become light-headed due to vasodilation and require assistance. The bag of water should be hung above the client's shoulder height, not at chest level. If the bag is hung lower, the rate of flow will not be sufficient, and water may cool too quickly. The client should be allowed to soak about 15 to 20 minutes, not 50 to 60 minutes.

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order. Inflammatory Proliferation Maturation Hemostasis

Hemostasis Inflammatory Proliferation Maturation The correct order of the phases of wound healing is hemostasis, inflammatory, proliferation, and maturation.

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? Gentle cleansing Wound irrigation Debridement Apply moist dressing

Wound irrigation With the yellow classification using the RYB wound classification system, wound irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? corticosteroids antihypertensive drugs potassium supplements laxatives

corticosteroids Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has prescribed fly larvae to debride the wound. Which type of debridement does the nurse understand has been prescribed? autolytic debridement surgical (sharp) debridement enzymatic debridement mechanical debridement

mechanical debridement The use of fly larvae (maggot therapy) is a form of mechanical debridement, because their mandibles and rough body surface scratch the necrotic tissue. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Surgical (sharp) debridement is the removal of necrotic tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: milia. prickly heat. acne vulgaris. lanugo.

milia. Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.

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 I stage II stage III stage IV

stage III Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage. Stage IV exposes muscle and bone.

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? supine oblique supine with the head of the bed elevated 45 degrees Trendelenburg

oblique The oblique position, an alternative to the side-lying position, results in significantly less pressure on the trochanter area. The nurse should not position the head of the bed above 30° unless medically contraindicated, and alternate right side, back, left side, and prone positions (when tolerated) using appropriate equipment to minimize friction and shearing.

The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force? preventing the client from sliding in bed pulling the sheets to reposition the client every 2 hours improving the client's hydration pulling the client up from under the arms

preventing the client from sliding in bed Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue. Pulling up from under the arms and pulling the sheets to reposition the client cause shearing force. Improving the client's hydration status could help with wound healing, but not in the prevention of shearing force.

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply. elevate the head of the bed 90 degrees four times daily provide incontinent care every 2 hours and as needed pull the client up in bed as needed turn the client every 2 hours when the client is in bed encourage the client to take fluids every 2 hours

provide incontinent care every 2 hours and as needed turn the client every 2 hours when the client is in bed encourage the client to take fluids every 2 hours Nursing interventions that will decrease the risk of pressure injury development include incontinent care every 2 hours and as needed, turning the client every 2 hours, and encouraging fluids every 2 hours. Factors that lead to pressure injury development include external pressure, friction, shear, immobility, inadequate nutrition and hydration, skin moisture, mental status, and age. Elevating the head of the bed 90 degrees four times daily increases pressure to the coccyx and sacral area and causes shearing. Pulling a client up in bed as needed should be avoided, as this causes shear.

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? gauze adhesive strips with eyelets transparent hydrocolloid

transparent Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist.

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? "Be sure to take at least two showers daily to remove all microorganisms from the skin." "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue. As such, clients should be taught to avoid soaps with artificial ingredients or fragrances, as these may be harsher on the skin. It is good to be clean; however, advice of taking at least two showers per day is excessive and may dry the skin. Moisturizer should be applied to the skin following bathing to prevent dryness of the skin. Drinking water is important to remain hydrated; however, the nurse should recommend drinking 1,500 to 2,000 mL of water daily. Drinking 8 ounces three times a day is 720 mL.

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 what type of injuries would the nurse be alert? Select all that apply. Broken left ankle Bruising Soft tissue damage Concussion Abrasions Dehydration

Broken left ankle Bruising Soft tissue damage Concussion Abrasions Skateboard related injuries that the nurse needs to assess for are a concussion and other brain injuries, broken bones, soft tissue injuries, and skin abrasions, cuts, and bruises. Symptoms of a concussion are dizziness, headaches, visual changes, loss of memory, slowed speech, and sensitivity to noise. An abrasion involves stripping of layers on the skin's surface. Soft tissue injuries include damage to the muscles, tendons, and ligaments. Dehydration can cause headaches and dizziness; however, since the client injured oneself while skateboarding a concussion should be suspected and assessed for. Because the client reported sliding on the sidewalk, the client should also be assessed for skin abrasions. Elevated thrombocytes would not be expected in a skateboard related injury.

Which is not considered a skin appendage? Hair Connective tissue Sebaceous gland Eccrine sweat glands

Connective tissue 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 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. Notify the health care provider of the findings. Document the findings in the client's medical record. Gently rub and massage the area to warm it up.

Discontinue the therapy and assess the client. The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? Contact the surgeon for debridement. Using sterile technique, debride the wound. Off-load pressure from the heel. Place an antiembolism stocking on the client's leg.

Off-load pressure from the heel. The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. The surgeon does not need to be consulted for a debridement. Utilizing an antiembolism stocking on the client will not impact the status of the heel wound.

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention? Use clean technique instead of sterile technique if the wound is closed. Apply petroleum jelly to the periwound skin to protect it from the irrigation solution. Stop irrigating when the solution from the wound turns light pink. If new bleeding is noted, continue irrigation cautiously and then notify the health care provider.

Use clean technique instead of sterile technique if the wound is closed. Clean technique can be used on a closed wound. When the solution from the wound turns clear, the irrigation should be discontinued. If bleeding is noted that was not previously there, the nurse should stop the irrigation and notify the health care provider. There is no need to apply petroleum jelly to the periwound skin.

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? transparent film hydrocolloid hydrogel alginate

hydrocolloid Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.

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? serous sanguineous serosanguineous purulent

serosanguineous Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink or pink-yellow. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: to provide a sinus tract for drainage. to provide drainage for bile. to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity.

to provide drainage for bile. A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition? eschar slough undermining dehiscence

undermining Undermining is the term for a hollow area between the outer wound and the wound bed. It resembles a cave. Eschar is a leathery covering that is dead tissue; it is usually removed by debridement. Tunneling is a cavity or channel formed from a wound. Dehiscence is the opening of a previously closed surgical wound.

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." "This is a complex reparative process." "The margins of your wound are not in direct contact." "The surgeon will leave your wound open intentionally for a period of time."

"Very little scar tissue will form." Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making? The nurse should apply adhesive wound closure strips after removing staples. The nurse should thoroughly irrigate the wound 15 to 30 minutes before the procedure. The nurse may delegate this task to unlicensed assistive personnel (UAP). The nurse should remove the staples in sequence, beginning at the proximal edge of the wound.

The nurse should apply adhesive wound closure strips after removing staples. After skin staples are removed, adhesive wound closure strips are applied across the wound to keep the skin edges approximated as the wound continues to heal. This task cannot be delegated to UAP. Irrigation is not necessary and alternating staples should be removed to prevent 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 copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing.

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. Draw the shape of the wound with a description. Measure the wound's length and width. Use a dry sterile applicator at a 90-degree angle to measure depth. Chart tunneling by using a quadrant approach to describe the location. Assess color, drainage, presence of pain, or complications.

Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications. When charting the findings, draw an irregular-shaped wound, as in this question, and provide a description including its length and width. A sterile applicator moistened with saline should be used to measure the depth of a wound and to determine the presence of tunneling. A dry applicator could damage the wound by sticking to it. The nurse would use the imaginary face of a clock when describing where on the wound the locations of tunneling exist. The nurse would assess the color of the wound, and presence of drainage, pain or discomfort, and any complications, and include these in the charting.

When applying an external heating pad, which prescription from the health care provider would the nurse question? Leave heating pad on for 45 minutes Assess site frequently during application of the heating pad Use gauze to secure the heating pad to the site of application Maintain the temperature between 105°F to 109°F (40.5°C to 43°C)

Leave heating pad on for 45 minutes The nurse should question the prescription to leave the heating pad on for 45 minutes, because this is too long and could cause complications such as burns. The maximum time limit should be no more than 30 minutes. Using heat for more than 30 minutes can result in tissue congestion, vasoconstriction, and increases the risk of tissue damage. It is important for the nurse to frequently assess the site during the application to ensure no adverse affects are occurring. The nurse should use either gauze or tape to hold the heating pad in the correct location; however, pins should not be used as they may puncture and damage the pad. The temperature should be maintained between 105°F to 109°F (40.5°C to 43°C) to ensure the best therapeutic results.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? Supports the area around the wound Maintains a moist environment Keeps the wound clean Reduces swelling and inflammation

Supports the area around the wound Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wrapped on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist.

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. 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.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? The nurse works outward from the wound in lines parallel to it. The nurse uses friction when cleaning the wound to loosen dead cells. The nurse swabs the wound with povidone-iodine to fight infection in the wound. The nurse swabs the wound from the bottom to the top.

The nurse works outward from the wound in lines parallel to it. A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.

The nurse would recognize which client as being particularly susceptible to impaired wound healing? an obese woman with a history of type 1 diabetes a client whose breast reconstruction surgery required numerous incisions a man with a sedentary lifestyle and a long history of cigarette smoking A client who is NPO (nothing by mouth) following bowel surgery

an obese woman with a history of type 1 diabetes Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

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

elevating and supporting the stump The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client? autolytic debridement biosurgical debridement enzymatic debridement mechanical debridement

mechanical debridement Mechanical debridement involves physical removal of necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed.

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound? hemostasis inflammatory phase proliferation phase maturation phase

proliferation phase The wound description reveals a beefy red wound bed that bleeds easily. This is the proliferation stage and describes granulation tissue. Hemostasis is the initial phase, involving activation of platelets. In the inflammatory phase, white blood cells and macrophages enter the wound to remove debris. The maturation phase involves collagen remodeling and scar formation.

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 stimulating the wound bed to promote the growth of granulation tissue removing purulent drainage from the wound bed in order to accurately assess it removing excess drainage and wet tissue to prevent maceration of surrounding skin

removing dead or infected tissue to promote wound healing Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Red classification Yellow classification Black classification Unstageable

Black classification A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System.

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? Infection of the wound Herniation of the wound Dehiscence of the wound Evisceration of the viscera

Dehiscence of the wound 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 health care provider. 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.

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. 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.

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? Contact the health care provider. Change the dressing. Document the findings. Notify the wound care nurse.

Document the findings. The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is no need to contact the health care provider or the wound care nurse. The nurse should not change the surgical dressing. Most often, the surgeon will change the first dressing in 24 to 48 hours. For this reason, the wound care nurse does not need to be notified.

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? stage I stage II stage III stage IV

stage II The area of redness and blister formation indicate that the client is experiencing a stage II pressure injury. A stage I pressure injury is intact but reddened. A stage III pressure injury has a shallow skin crater that extends to the subcutaneous tissue. A stage IV pressure injury is severe; the tissue is deeply ulcerated and exposes muscle and bone with the presence of necrotic tissue likely.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? stage I stage II stage III stage IV

stage IV Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

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. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Carefully pick the crusts off the sutures with the forceps before removing them. Do not attempt to remove the sutures because the wound needs more time to heal.

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client? Monitor intake and output. Assess the coccyx area for blanching. Monitor the client for nausea. Assess mental status.

Monitor intake and output. A client with diarrhea caused by Clostridium difficile is at risk for dehydration. As such, the priority assessments should include intake and output, skin turgor, condition of mucous membranes, and vital signs. Assessing the coccyx area for blanching should be done with shift assessments; however, circulating fluid volume takes priority. Monitoring for nausea and assessing the client's mentation is not directly related to the effects of the infectious diarrhea.

A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product? The dressing allows for absorption of drainage. The dressing provides a sterile wound environment. The dressing allows oxygen exchange between the wound and environment. The dressing may safely be left in place for up to 10 days.

The dressing allows oxygen exchange between the wound and environment. Transparent films allow for oxygen exchange between the wound and the environment. They do not absorb any drainage and they are normally left in place for up to 72 hours. Sterility is not conferred simply by the application of a wound dressing.

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery? physiologic defense immediately after the tissue injury period during which new cells fill and seal a wound process by which damaged cells recover and reestablish normal function period during which the wound undergoes changes and maturation

period during which the wound undergoes changes and maturation The remodeling phase can be described as the period during which the wound undergoes changes and maturation. The remodeling phase follows the proliferative phase and may last 6 months to 2 years. The inflammatory phase is the physiologic defense immediately after tissue injury. The proliferation phase is the period during which new cells fill and seal the wound. Resolution is the process by which damaged cells recover and reestablish normal function. This forms part of the proliferation phase.

What intervention(s) should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply. proper client nutrition 2-hour turn schedule pressure redistribution support surfaces head of bed positioned at 45 degrees pillow placed under knees client repositioning with a lift

proper client nutrition 2-hour turn schedule pressure redistribution support surfaces client repositioning with a lift To protect clients at risk for the adverse effects of pressure, the nurse will implement turning on an every-2-hours schedule in the health care setting. More frequent position changes may be necessary, depending on the client. Use of a pressure redistribution support surface can be expensive, but it is an effective way to prevent a pressure injury. The nurse will also keep heels from pressing on the bed for immobile clients and advise against prolonged sitting. While sitting or lying, the client will use positioning devices or pillows to keep boney prominences from rubbing on each other or pressing onto a surface. Placing pillows under the knees while supine puts pressure on the heels against the mattress. The nurse will protect the client's skin from friction and shear by lifting the client when moving or repositioning and keep the head of bed at 30 degrees or less. Positioning at client on a bed while the head of the bed is at a 45 degree angle could cause the client to have a skin shear or friction injury. The nurse will provide adequate calories and nutrients.

The client, after undergoing an appendectomy for a ruptured appendix, has an open drain left in the wound. The health care provider prescribes removal of 2 in (5 cm) of drain every day. Which action will the nurse take? reposition the safety pin or clip on the drain apply extra dressing to absorb continued drainage weigh the soiled dressing to determine approximate drainage document only this action and client response

reposition the safety pin or clip on the drain A drain is left in the wound to assist with capillary drainage of fluids, especially after a ruptured appendix. A safety pin or clip is placed on the drain to prevent it from slipping into the wound. As the nurse withdraws the drain, the safety pin or clip must be relocated to keep the drain at the correct location. There should be no need to apply extra dressing as the drainage is usually decreased by this time, which is part of the rationale to slowly remove it. There is no need to weigh the soiled dressing. The nurse should document and record the response of the client after all interactions, not just this technique.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "Do you experience incontinence?" "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?"

"Do you experience incontinence?" The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

The nurse is caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states, "My pain medication is effective, but will this pain ever get better and go away?" Which response is correct? "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." "It is unusual for you to still have severe pain. I will contact your surgeon." "If the prescribed analgesics are controlling the pain, we do not worry about the severity of the pain." "If the pain does not subside by this time tomorrow, you will need to be screened for the development of chronic pain."

"Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." Surgical incisional pain is usually most severe for the first 2 to 3 days and then progressively diminishes. It is imperative that nurses teach clients about the progression of pain postsurgery. The client should still be assessed for pain and the pain scale should be documented in the client's medical record. The development of chronic pain is persistent pain after 6 months.

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? "This is normal tissue." "That is called slough, and it will usually fall off." "You are seeing undermining, a type of tissue erosion." "Necrotic tissue is devitalized tissue that must be removed to promote healing."

"Necrotic tissue is devitalized tissue that must be removed to promote healing." The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

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." 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.

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? (LPN is using glove with her finger to apply cream) "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." "This procedure can be safely preformed using clean technique if care is taken not to touch the wound." "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. "Very little scar tissue will form." "This is a simple reparative process." "The margins of your wound are widely separated." "Your wound will be purposely left open for a time." "Your wound edges are right next to each other."

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other." Very little scar tissue is expected to form during first-intention healing in a wound whose wound edges are close to each other. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

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." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "As soon as the infection clears, your surgeon will staple the wound closed."

"Your wound will heal slowly as granulation tissue forms and fills the wound." This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.

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. A Penrose drain is a closed drainage system that is connected to an electronic suction device. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

A Penrose drain promotes passive drainage into a dressing. A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? Apply a skin protectant to the skin around the incision. Apply a skin protectant to the incision site. Apply a sterile gauze sponge over the incision site. Apply a transparent dressing over the incision site.

Apply a skin protectant to the skin around the incision. Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied.

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply. Administer analgesia before changing the dressing around the drain, if needed. Perform hand hygiene and put on goggles before emptying the drain. Use a gauze pad to clean the drain outlet after emptying it. Leave the drain open for 5 to 7 minutes to ensure full drainage. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.

Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it. Analgesia can be provided before drain care, if necessary. A gauze pad is used to cleanse the outlet after emptying and the drain is secured to the client's gown with a safety pin. Goggles are not normally necessary. The drain does not require 5 to 7 minutes in order to become fully empty.

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? Use an aquathermia pad during the treatment to create heat and circulate the water. Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles.

Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Warm soaks and dressing changes can be painful for clients with abscesses. Often, nurses will premedicate with pain medications, often opioids, 20 to 30 minutes prior to make the treatments more comfortable for clients. Increasing client comfort can increase effectiveness by allowing the nurse time to adequately perform the treatment, assess the wound, and apply the new dressing. Aquathermia pads are used to promote wound healing, but they are not used simultaneously with water therapies. Dangling the legs and ambulating will not increase comfort.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Avoid using irrigation to clean the wound before changing the dressing. Apply dry gauze to the wound and carefully apply saline to saturate it. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

Which action should the nurse perform when applying negative pressure wound therapy? Cut foam to the shape of the wound and place it in the wound. Increase the negative pressure setting until drainage is brisk. Irrigate the wound thoroughly using normal saline and clean technique. Test the seal of the completed dressing by briefly attaching it to wall suction.

Cut foam to the shape of the wound and place it in the wound. When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the health care provider, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

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 Perform passive range-of-motion exercises Massage skin surfaces daily, especially areas under pressure and bony prominences Frequently orient client to place and situation

Implement a 2-hour repositioning schedule The nurse must regularly turn and reposition the client who is immobile to prevent ischemia and consequent skin breakdown. Other skin integrity interventions include monitoring skin for changes, monitor client's continence status and prevent or minimize exposure to urine and feces, evaluate need for positioning devices and specialty mattresses, nutritional status assessment, and individualize skin care plan. Range-of-motion exercises are good to combat problems related to immobility. Frequent orientation is helpful for clients with dementia. Massage may promote circulation, but it is less important than turning the client on a scheduled basis, and massaging areas over bony prominences could harm the skin's integrity.

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? Notify the surgeon STAT Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration. Approximating the wound edges and applying wound closure tapes may cause the client undue pain and trap bacteria in the wound. Irrigating the open wound may cause unwanted bacteria from the surrounding area to wash into the wound.

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client? Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs Placing the client in the supine position with a pillow under the knees Placing the client in a side-lying position with a pillow between the lower legs Placing the client in a wheelchair with the back of the feet resting against the heel loops

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues. Pressure points in bed vary depending on the size and shape of client and the position. Pressure points while sitting in a chair or wheelchair also vary depending of the style, shape, and construction of the chair or wheelchair, the clients position in the chair, and the size and shape of the client. Any boney prominence or areas under a large amount of pressure against a hard or semihard surface can create a pressure injury. To protect clients at risk for pressure injury, the nurse implements a 2-hour turn schedule, uses a pressure redistribution support surface, keeps pressure points from pressing on the bed or chair by using positioning devices or pillows, keeps boney prominences from rubbing on each other, minimizes exposure of skin to incontinence, perspiration, or wound drainage, and provides adequate calories and nutrients. A pillow placed between the lower legs in side-lying position will prevent ankle to ankle pressure, but not ankle to mattress pressure. Placing a pillow under the knees while positioned supine will increase pressure on the heels. While using a wheelchair, it is best to have the client wear well-fitted shoes and position the feet on the footplate and remove the heel rest or heel loop.

The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action? Don sterile gloves before manipulating the cap of the drain. Cleanse the area around the cap with alcohol for 30 seconds before removing it. Pin the drain to the client's gown after pulling the tubing taut. Recompress the drain before replacing the cap.

Recompress the drain before replacing the cap. Recompressing the drain after replacing the cap would force air and exudate into the client, causing pain and posing an infection risk. Gloves are necessary for this procedure, but they do not need to be sterile. It is unnecessary to cleanse the area around the cap with alcohol. It is important that the tubing should not be under tension.

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? Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

Rotate the swab several times over the wound surface to obtain an adequate specimen. The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? Secure the drain to the client's gown with a safety pin below the level of the wound. Tape the drain to the dressing material securely below the level of the wound. Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. Apply an abdominal binder over the entire wound and drain to support the site.

Secure the drain to the client's gown with a safety pin below the level of the wound. To ensure there is not any tension on the tubing of a Jackson-Pratt drain, the nurse should secure the drain to the client's gown with a safety pin below the level of the wound. Taping the drain or applying an abdominal binder will keep the bulb compressed and hinder the suction action of the drain. The drain should not be allowed to hang freely because this causes tension on the drain site.

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 I Stage II Stage III Stage IV

Stage II A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day? The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain. The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain. The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain.

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. Sometimes the health care provider orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To splint the area when engaging in activity To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing

To splint the area when engaging in activity To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? a newborn a client with cardiovascular disease an older client with arthritis a critical care client

a critical care client Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client.

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: an allergic reaction to medications. an allergic reaction to detergent. a rash related to a yeast infection. a rash related to immobility.

a rash related to a yeast infection. Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.

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 to facilitate rehydration. What type of dressing will 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 Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protect the site from microorganisms. Gauze dressings—precut, with an adherent coating, premedicated with antibiotics—do not allow the nurse to visualize the site without partially or completely removing the dressing.

A client's risk for the development of a pressure injury is most likely due to which lab result? albumin 2.5 mg/dL glucose 110 mg/dL hemoglobin A1C 7% sodium 135 mEq/L

albumin 2.5 mg/dL An albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury. A hemoglobin A1C level greater than 8% puts the client at risk for the development of pressure injuries due to a prolonged high glucose level. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not put the client at risk for the development of a pressure injuries.

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who eats a diet high in vitamins A and C a client who is taking corticosteroid drugs a 10-year-old client with a surgical incision

an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drugs There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure injury formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client. A client who eats a diet high in vitamins A and C would not be at risk for delayed wound healing. A 10-year old client with a surgical incision would not be at risk for delayed wound healing.

The nurse has delegated applying an elastic bandage with clips to the right knee of a 12-year-old client to the unlicensed assistive personnel (UAP). Which action will the nurse determine the UAP needs additional training? applies wrap from proximal to distal direction uses a figure-of-8 technique keeps bandage free of wrinkles used metal clips to secure end of bandage

applies wrap from proximal to distal direction A roller bander or elastic bandage with clips should be applied from a distal to proximal direction. The other actions are all correct steps to use to apply a bandage, especially to the knee.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon applying sterile dressings with normal saline over the protruding organs and tissue assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound

applying sterile dressings with normal saline over the protruding organs and tissue The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care? cleanse the wound from the outer area toward the inner area cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing cleanse the wound in parallel strokes from the top to the bottom of the wound cleanse with a new gauze for each stroke

cleanse with a new gauze for each stroke When cleansing a wound, the nurse should use a new gauze or swab on each downward stroke of the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside.

A full-thickness or third-degree burn develops a leathery covering called a(an): eschar. static. abrasion. erythema.

eschar. The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.

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 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.

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