NM4310 Tissue

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct. 1 Switch positions every 4 hours. 2 Use a heating pad for the first 24 hours. 3 Apply for 30-minute time intervals. 4 Place the ice pack directly to injury site. 5 Take ibuprofen every 4 hours PRN.

Apply for 30-minute time intervals. RATIONALE: To prevent skin damage, ice and heat should only be applied for 20- to 30-minute intervals. Clients should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue. The client can take ibuprofen if approved by the health care provider.

How would the nurse describe the exudate characteristic of a serosanguineous wound? 1 Greenish-blue pus 2 Creamy yellow exudate 3 Blood-tinged amber fluid 4 Beige pus with a fishy odor

Blood-tinged amber fluid RATIONALE: Blood-tinged amber fluid is characteristic of serosanguineous wound exudate. Greenish-blue pus, creamy yellow exudate, and beige pus with a fishy odor are characteristics of purulent wound exudate.

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? 1 Atrophy of the sweat glands 2 Decreased subcutaneous fat 3 Stiffening of the collagen fibers 4 Degeneration of the elastic fibers

Decreased subcutaneous fat RATIONALE: In older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers. Atrophy of the sweat glands will cause dry skin and decreased body odor. Stiffening of the collagen fibers and degeneration of the elastic fibers will result in the development of wrinkles.

While providing care for an obese client who underwent an open cholecystectomy, the nurse identifies a separation in the surgical incision. Which complication is the client experiencing? 1 Adhesions 2 Dehiscence 3 Evisceration 4 Contractions

Dehiscence RATIONALE: Dehiscence is the separation and disruption of previously joined wound edges; this condition typically occurs in obese clients. Adhesions are bands of scar tissue that form between or around organs. Evisceration occurs when wound edges separate to the extent that intestines protrude through the wound. Contractions are a normal part of healing, but excessive contractions result in deformity.

When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? 1 Avoid massaging the client's legs. 2 Frequently reposition the client on a scheduled basis. 3 Increase the fiber content in the client's food. 4 Encourage the client to participate in weight-bearing exercises.

Frequently reposition the client on a scheduled basis. RATIONALE: Frequent repositioning of the client in bed or wheelchair on a scheduled basis will relieve pressure points, thereby decreasing potential development of pressure ulcers. Avoiding leg massages will decrease the risk of embolism, but does not prevent pressure ulcers. Increased intake of dietary fiber will relieve the immobilized client of constipation. Weight-bearing exercises will prevent the immobilized client from developing muscular atrophy or loss of calcium from the bone.

For which medication would the nurse monitor the serum creatinine and blood urea nitrogen (BUN) levels, when administered to a client receiving therapy for extensive burn wounds? 1 Nitrofurantoin 2 Mafenide acetate 3 Silver sulfadiazine 4 Gentamicin sulfate

Gentamicin sulfate RATIONALE: Gentamicin sulfate may cause nephrotoxicity in the client; therefore the nurse would monitor the client prescribed this medication for serum creatinine and BUN changes. The nurse monitors the client on nitrofurantoin for signs of allergic reactions. Mafenide acetate requires monitoring of blood gases and serum electrolyte levels. In clients who are on silver sulfadiazine, the nurse monitors the wounds for infections.

An abscess develops in an obese adult after abdominal surgery. The wound is healing by secondary intention. Which diet would the nurse expect the health care provider to prescribe to meet this client's immediate nutritional needs? 1 Low in fat and vitamin D 2 High in calories and fiber 3 Low in residue and bland 4 High in protein and vitamin C

High in protein and vitamin C RATIONALE: Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.

A client is admitted with extensive bone and soft-tissue injuries to the leg and sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. Which action would the nurse take to loosen the dressing? 1 Apply diluted hydrogen peroxide. 2 Pull with gentle but steady traction. 3 Soak the area in a solution of Betadine. 4 Moisten the dressing with sterile saline.

Moisten the dressing with sterile saline. RATIONALE: Sterile saline will soften the dried exudates adhered to the dressing, limiting tissue damage when the dressing is removed. The use of hydrogen peroxide can be irritating to the tissues. Pulling off the dressing with steady traction may be painful and cause unnecessary tissue damage. The use of Betadine to remove a dressing is not recommended.

Which type of debridement would the health care provider schedule for a client who requires removal of large amounts nonviable tissue, quickly? 1 Surgical debridement 2 Autolytic debridement 3 Enzymatic debridement 4 Mechanical debridement

Surgical debridement RATIONALE: Surgical debridement removes large amounts of nonviable tissue in a quick manner. Autolytic debridement is a semiocclusive or occlusive dressing used to soften dry eschar via autolysis. Enzymatic debridement topically dissolves necrotic tissue, and involves placement of a moist dressing over the necrotic tissues. Mechanical debridement includes three methods: wet-to-dry dressings, wound irrigation, and whirlpool. The process occurs over time.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse would document the assessment finding as which stage of pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable

Unstageable RATIONALE: A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.