Prep U Ch 32: Skin Integrity and Wound Care

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."

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

Broken left ankle, bruising, and dehydration and elevated thrombocytes

Which is not considered a skin appendage

Connective tissue

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next

Document the color, odor, amount, and type of wound drainage.

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

Evisceration

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

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.

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.

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.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable.What is the best way to document the nurse's assessment finding

Stage 1 Pressure ulcer

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

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

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

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document

serosanguineous

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

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 injury

use pillows to maintain a side-lying position as needed

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure

Clean the wound from the top to the bottom and from the center to outside.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound

Corticosteroids

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse

Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

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 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."

An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor

Adipose tissue is poorly vascularized.

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.

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 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.

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

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

Tetanus, infection, wound care, and pain control

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

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

Warm hand Fingers with quick capillary refill No finger numbness or tingling

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 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

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention

applying sterile dressings with normal saline over the protruding organs and tissue

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing

contusion

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for

dehiscence.

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 Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture.

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

foul-smelling drainage that is grayish in color

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 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

"It allows removal of blood and drainage from the surgical wound."

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching

"Reinforced adhesive skin closures will hold my wound together until it heals."

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 drainage passively into a dressing.

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

A T-tube is used to drain bile,

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

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 bestaction by the nurse at this time

Discontinue the therapy and assess the client.

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 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

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury

preventing the client from sliding in bed

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely

second degree or partial thickness

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

the client has fistula formation

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

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