Fundamentals Chapter 32
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?"
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?
"I will put a layer of cloth between my skin and the ice pack."
The nurse is 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?
"It provides a way to remove drainage and blood from the surgical wound."
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?
"Necrotic tissue is devitalized tissue that must be removed to promote healing."
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?
"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
the nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?
"This is necrotic tissue, which must be removed to promote healing."
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."
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.
The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?
Apply saline solution-moistened gauze over the protruding area.
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.
The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?
Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."
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.
Cyanosis *Decreased radial pulse *Fingers with quick capillary refill *Warm hand *No finger numbness or tingling
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?
Dehiscence of the wound
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
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.
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?
Fish
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?
Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
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?
Off-load pressure from the heel.
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen.
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?
Stage II
The nurse is caring for an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help the potential for pressure injuries
Stages of pressure injuries *Nutritional status *Mental status *Skin moisture *Sensory perception
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
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 oxygen exchange between the wound and the environment.
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 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 is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?
The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?
a sterile, flexible applicator moistened with saline
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
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
The nurse would recognize which client as being particularly susceptible to impaired wound healing?
an obese woman with a history of type 1 diabetes
The nurse 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
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
corticosteroids
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
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?
period during which the wound undergoes changes and maturation
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?
secondary intention
A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage
serosanguineous
A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?
The status of the client's tetanus immunization
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
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?
stimulating the wound bed to promote the growth of granulation tissue
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?
transparent
