Integument Quizlet
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. a) True b) False
A
A client has developed blisters around the tape that secures the dressing. The nurse should: a) apply the dressing with a binder. b) apply tape to the side of the blisters. c) apply skin barrier to protect skin. d) use Montgomery straps.
A
A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage? a) Serosanguineous b) Sanguineous c) Serous d) Purulent
A
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? a) Suspected deep tissue injury b) Stage II c) Unstageable d) Stage III
A
A nurse is caring for a client who has an avulsion of her left thumb. Which of the following descriptions should the nurse understand as being the definition of avulsion? a) Tearing of a structure from its normal position b) Puncture of the skin c) Cutting with a sharp instrument with wound edges in close approximation with correct alignment d) Tearing of the skin and tissue with some type of instrument: tissue not aligned
A
A nurse is evaluating a client's laboratory data. Which of the following laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development? a) Albumin 2.8 mg/dL b) White blood cell count 14,800 mm3 c) Hemoglobin A1C 5% d) Blood urea nitrogen (BUN) 7 mg/dL
A
An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? a) a transparent film b) a gauze dressing precut halfway to fit around the IV line c) a gauze dressing premedicated with antibiotics d) a dressing with a nonadherent coating
A
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? a) "Your wound will heal slowly as granulation tissue forms and fills the wound." b) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." c) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." d) "As soon as the infection clears, your surgeon will staple the wound closed."
A
The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment? a) "Do not douche 24-48 hours before the procedure." b) "Douching is recommended so that you are clean for the examination." c) "The Pap procedure includes application of a douche." d) "Plan to begin douching routinely immediately after your procedure."
A
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a) a surgical incision with sutured approximated edges b) a large wound with considerable tissue loss allowed to heal naturally c) a wound healing naturally that becomes infected. d) a wound left open for several days to allow edema to subside
A
The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing? a) Fish b) Pasta salad c) Green beans d) Banana
A
The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority? a) Impaired tissue integrity b) Knowledge deficit c) Acute pain d) Disturbed body image
A
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? a) Elevate and support the stump. b) Exert equal, but not excessive, tension with each turn of the bandage. c) Wrap distally to proximally. d) Keep bandage free from gaps between each turn.
A
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? a) Tegaderm b) gauze c) Montgomery straps d) DuoDerm
A
The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot, and injured the worker's foot. What type of injury does the nurse anticipate? a) puncture b) incision c) avulsion d) contusion
A
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 client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a) Desiccation b) Evisceration c) Maceration d) Necrosis
A
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? a) incision b) laceration c) avulsion d) abrasion
A
Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a client's wound? Select all that apply. a) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. b) Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. c) Position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. d) Using clean technique, open the supplies and dressings and place the fine-mesh gauze into the basin, pouring the ordered solution over the mesh to saturate it. e) Put on clean gloves and squeeze excess fluid from the gauze dressing before packing it tightly in the wound. f) Apply one dry, sterile gauze pad over the wet gauze, and then place an ABD pad over the gauze pad.
ABC
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? a) "I place antibiotic ointment in the bulb and squeeze it into the wound." b) "It allows for removal of blood and drainage from the surgical wound." c) "The drain is part of the knee replacement; it stays attached permanently." d) "This drain decreases the pain associated with the knee replacement."
B
A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? a) Stage IV b) Stage II c) Stage I d) Stage III
B
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? a) removing excess drainage and wet tissue to prevent maceration of surrounding skin b) removing dead or infected tissue to promote wound healing c) stimulating the wound bed to promote the growth of granulation tissue d) removing purulent drainage from the wound bed in order to accurately assess it
B
A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition? a) There is redness or inflammation of an area as a result of dilation. b) There is an unintentional separation of the wound. c) There is an accumulation of fluid in the interstitial tissue. d) The edges of the wound are lightly pulled together.
B
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 of the following nursing actions should the nurse perform? a) Debridement b) Wound irrigation c) Gentle cleansing d) Apply moist dressing
B
A physician orders a wound irrigation to apply an antiseptic to a client's wound. The nurse will follow which guideline for performing this procedure? a) If bleeding is noted that was not previously there, the nurse should continue irrigation and then notify the physician. b) If the wound is closed, clean technique may be used instead of sterile technique. c) When the solution from the wound turns light pink, the irrigation should be stopped. d) Sterile water is often the solution of choice when irrigating wounds.
B
Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? a) The heart must be able to pump adequately. b) Local capillary pressure must be lower than external pressure. c) The volume of circulating blood must be sufficient. d) Arteries and veins must be patent and functioning well.
B
The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The oncoming nurse receives in 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? a) Use an aquathermia pad during the treatment to create heat and circulate the water. b) Administer analgesics 30 minutes prior to the treatment to act on pain receptors. c) Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. d) Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles.
B
The nurse has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn? a) OpSite b) gauze c) Montgomery strap d) Tegasorb
B
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 of the following actions should the nurse perform in obtaining a wound culture? a) Stroke the culture swab on surrounding skin first. b) Keep the swab and inside of the culture tube sterile. c) Utilize the culture swab to obtain cultures from multiple sites. d) Cleanse the wound after obtaining the wound culture.
B
The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include? a) "This is a complex reparative process." b) "Very little scar tissue will form." c) "The surgeon will leave your wound intentionally open for a period of time." d) "The margins of your wound are not in direct contact."
B
When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? a) ischemia b) shearing force c) friction d) necrosis of tissue
B
Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. a) Clean from the outside of the wound to the center. b) Use a sterile applicator to apply any ointment that is ordered. c) Use a new gauze for each wipe of the wound. d) Avoid touching the wound bed, whether with gloves or forceps. e) Clean the wound from top to bottom.
BCDE
A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? a) Stage IV b) Stage III c) Stage II d) Stage I
C
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure ulcer development? a) Morse scale b) FLACC scale c) Braden scale d) Glascow scale
C
A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? a) Once the wound is cleaned, dry the area with an absorbent cloth. b) Clean the wound from the bottom to the top, and outside to center. c) Clean the wound from the top to the bottom, and center to outside. d) Use clean technique to clean the wound.
C
A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn? a) may vary from brown or black to cherry red or pearly white; bullae may be present b) superficial, may be pinkish or red with no blistering c) usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown d) also called a superficial partial-thickness burn, can appear dry and leathery
C
A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? a) Direction b) Size c) Depth d) Tunneling
C
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? a) "As soon as the infection clears, your surgeon will staple the wound closed." b) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." c) "Your wound will heal slowly as granulation tissue forms and fills the wound." d) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal."
C
The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? a) Assess the client's mental status. b) Assess for the use of antihypertensives. c) Assess the wound for active bleeding. d) Assess the client for claustrophobia.
C
The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate? a) "Dehiscence is a total separation of the wound with protrusion of the viscera through it." b) "Dehiscence is not anything that you need to worry about." c) "Dehiscence is when a wound has partial or total separation of the wound layers." d) "Dehiscence is the softening of tissue due to excessive moisture."
C
The nurse would recognize which client as being particularly susceptible to impaired wound healing? a) a client whose breast reconstruction surgery required numerous incisions b) a man with a sedentary lifestyle and a long history of cigarette smoking c) an obese woman with a history of type 1 diabetes d) A client who is n.p.o. (nothing by mouth) following bowel surgery
C
What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? a) hydrogels b) transparent films c) hydrocolloid dressings d) alginates
C
A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the client's chance of skin breakdown? a) Ensure the client is adequately hydrated. b) Massage or stimulate the client's skin surfaces daily. c) Keep the client in a semi-Fowler's or high-Fowler's position. d) Reposition the client on a regular basis.
D
A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention? a) Contact the surgeon. b) Monitor for pallor and mottle appearance of the wound. c) Assess for impaired blood flow to the area of evisceration. d) Apply sterile dressings with normal saline over the protruding organs and tissue.
D
A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? a) Stage IV b) Stage III c) Stage I d) Stage II
D
A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? a) Stage I b) Stage IV c) Stage II d) Stage III
D
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure ulcer? a) Place a foot board on the bed. b) Elevate the head of the bed 90 degrees. c) Provide incontinent care every 4 hours as needed. d) Use pillows to maintain a side-lying position as needed.
D
A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? a) Autolytic debridement b) Mechanical debridement c) Enzymatic debridement d) Biosurgical debridement
D
A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a) Pick the crusts off the sutures with the forceps before removing them. b) Do not attempt to remove the sutures because they need more time to heal. c) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. d) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.
D
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 describes this? a) Tertiary intention b) Primary intention c) Maturation d) Secondary intention
D
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a) A child's skin becomes less resistant to injury and infection as the child grows. b) In children younger than 2 years, the skin is thicker and stronger than in adults. c) An individual's skin changes little over the life span. d) An infant's skin and mucous membranes are easily injured and at risk for infection.
D
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? a) Herniation of the wound b) Infection of the wound c) Evisceration of the viscera d) Dehiscence of the wound
D
The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces? a) a client who must remain on his back for long periods of time b) a client who lifts himself up on his elbows c) a client who lies on wrinkled sheets d) a client sitting in a chair who slides down
D
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? a) The nurse uses a safety pin to attach the pad to the bedding. b) The nurse places the heating pad under the client's neck. c) The nurse covers the heating pad with a heavy blanket. d) The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
D
The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication? a) Hemorrhage b) Dehiscence c) Fistula d) Evisceration
D
The nurse is caring for a client who has a heavy exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? a) An antimicrobial dressing such as SilvaSorb b) A hydrogel dressing such as Aquasorb c) Transparent film such as Tegaderm d) An alginate dressing such as AlgiCell
D
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) an otic curette b) a sterile tongue blade lubricated with water soluble gel c) a small plastic ruler d) a sterile, flexible applicator moistened with saline
D
The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching? a) "I will not remove the staples myself." b) "I may have staples in place for a number of days." c) "After delivery, I will have sutures in place." d) "Steri-Strips will hold my wound together until it heals."
D
Which is not a protective function of the skin? a) Sebum gives the skin an acidic pH, which retards the growth of microorganisms. b) It contains cells such as macrophages that protect it. c) Microorganisms that inhibit the growth of pathogens are present on the skin. d) Keratin protects against the sun's ultraviolet rays.
D
Which is not considered a skin appendage? a) Eccrine sweat glands b) Hair c) Sebaceous gland d) Connective tissue
D
Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer? a) Pull client up under the arms. b) Improve the client's hydration c) Support the client from sliding in bed. d) Lubricate the area with skin oil.
c
