Nursing Fundamentals Chapter 31.
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?
"Dehiscence is when a wound has partial or total separation of the wound layers."
To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?
"Do you experience incontinence?"
The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate?
"Wounds heal better when a moist wound bed is maintained."
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
Which best describes the third phase of the wound healing process: proliferative?
Epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization.
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?
Fish
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
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?
The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?
Transparent
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."
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?
An infant's skin and mucous membranes are easily injured and at risk for infection.
The healthcare 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?
Assess the wound for active bleeding.
A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure?
Clean the wound from the top to the bottom, and center to outside.
Which is not considered a skin appendage?
Connective tissue
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
Corticosteroids
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?
Keep the swab and inside of the culture tube sterile.
Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which of the following is not one of these factors?
Local capillary pressure must be lower than external pressure.
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?
Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.
The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, the nurse will incorporate which nursing measure?
Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change.
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 the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize with this client's wound?
Proliferation Phase
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?
Secondary intention
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?
Stage II A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater. A stage I pressure ulcer 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 ulcer 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. Ulcers at this stage may include undermining and tunneling. Stage IV ulcers 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.
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?
Stage III
Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?
Support the client from sliding in bed.
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
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?
Use pillows to maintain a side-lying position as needed.
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 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
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 transparent film
A woman 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. The client has a(an):
fistula
What is true about the dermis? Select all that apply.
• It is responsible for producing the proteins collagen and elastin. • It is the thickest skin layer.
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 is taking corticosteroid drugs