PREPU CHAPTER 31 SKIN INTEGRITY & WOUND CARE

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) White blood cell count 14,800 mm3 b) Blood urea nitrogen (BUN) 7 mg/dL c) Albumin 2.8 mg/dL d) Hemoglobin A1C 5%

C

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) Keep the swab and inside of the culture tube sterile. b) Stroke the culture swab on surrounding skin first. c) Utilize the culture swab to obtain cultures from multiple sites. d) Cleanse the wound after obtaining the wound culture.

A

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) A hydrogel dressing such as Aquasorb b) An antimicrobial dressing such as SilvaSorb c) An alginate dressing such as AlgiCell d) Transparent film such as Tegaderm

A Antimicrobial dressings are appropriate for chronic wounds at risk for infection.

During a skin assessment, the nurse recognizes the first indication that a pressure ulcer may be developing when the skin is which color during the application of light pressure? a) White b) Red c) Blue-grey d) Yellow

B

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? a) Maintains a moist environment b) Reduces swelling and inflammation c) Keeps the wound clean d) Supports the area around the wound

D

A nurse assessing the skin of clients knows that the following are health states that may predispose clients to skin alterations. Select all that apply. a) Obesity b) Cataracts c) Hypertension d) Low BMI e) Excessive perspiration

ADE

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) Serous b) Sanguineous c) Serosanguineous d) Purulent

C

A nurse is documenting 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 types should the nurse document? a) Sanguineous b) Purulent c) Serosanguineous d) Serous

C

A student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as "unstageable." Which wound description should the student nurse expect to assess? a) The wound is a 3 cm × 5 cm blood-filled blister. b) The wound is 3 cm × 5 cm with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. c) The wound is 3 cm × 5 cm with yellow tissue covering the entire wound. d) The wound is 3 cm × 5 cm with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible.

C

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? a) Jackson-Pratt drain b) Hemovac drain c) Penrose drain d) Wound pouching

C Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. Jackson-Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery. Wound pouching is used on wounds that have excessive drainage.

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? a) The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain. b) 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. c) The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain. d) The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain.

B

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) Secondary intention d) Maturation

C Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue and, eventually, epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as wounds with clean surgical incisions or shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when a delay happens between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question? a) "How many meals a day do you eat?" b) "Have you had any recent illnesses?" c) "Do you experience incontinence?" d) "Do you use any lotions on your skin?"

C The client's health history is an essential component for assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture).

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? a) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. b) The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. c) The nurse packs the wound cavity tightly with dressing material. d) The nurse uses wet-to-dry dressings continuously.

A A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist.

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client? a) Mechanical debridement b) Biosurgical debridement c) Enzymatic debridement d) Autolytic debridement

A

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a) Off-load pressure from the heel. b) Place a TED hose on the client's leg. c) Using sterile technique, debride the wound. d) Contact the surgeon for deibridement.

A

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) shearing force b) necrosis of tissue c) friction d) ischemia

A

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? a) The nurse works outward from the wound in lines parallel to it. b) The nurse uses friction when cleaning the wound to loosen dead cells. c) The nurse swabs the wound with povidone-iodine to fight infection in the wound. d) The nurse swabs the wound from the bottom to the top.

A A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty.

A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain? a) Provides drainage for bile b) Provides a sinus tract for drainage c) Diverts drainage to the peritoneal cavity d) Decreases dead space by decreasing drainage

A A t tube is used to brain bile such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage? a) in the axilla b) under the client c) under the skin d) on the output sheet

B

A nurse is caring for a client who has a 6-cm × 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 best to be ordered by the primary care provider? a) Hydrocolloid b) Alginate c) Transparent d) Hydrogel

B

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) Mechanical debridement b) Biosurgical debridement c) Enzymatic debridement d) Autolytic debridement

B

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 the skin and tissue with some type of instrument: tissue not aligned b) Tearing of a structure from its normal position c) Puncture of the skin d) Cutting with a sharp instrument with wound edges in close approximation with correct alignment

B

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care? a) Cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing. b) Cleanse the wound using parallel stroke from the top to the bottom of the wound. c) Cleanse the wound from the outer area towards the inner area. d) Cleanse with a new gauze for each stroke.

B

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): a) evisceration. b) fistula. c) infection. d) dehiscence.

B

The nurse is caring for a client in the emergency department who cut herself 15 minutes ago while preparing dinner at her home. The nurse understands the client's wound is in which phase of wound healing? a) Inflammatory phase b) Hemostasis phase c) Proliferation phase d) Maturation phase

B

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? a) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. b) Reduce the time interval between dressing changes. c) Use less packing material. d) Assure that the packing material is completely saturated when placed in the wound.

B

The nurse caring for client that had abdominal surgery 12 hours ago notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? a) Notify the wound care nurse. b) Document the findings. c) Contact the physician. d) Change the dressing.

B The nurse should document the findings and continue to monitor the dressing. As it is a small amount of drainage, there is no need to contact the physician or the wound care nurse. The nurse should not change the dressing, as the dressing is still the surgical dressing and most often the surgeon will change the first surgical dressing within 24 to 48 hours.

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.) a) A wound that is covered with thick eschar b) A wound with drainage that is a beige color c) A wound that is characterized by oozing from the tissue covering the wound d) A wound that reflects the color of normal granulation tissue e) A wound that is treated by using sharp, mechanical, or chemical dÉbridement f) A wound that requires wound cleaning and irrigation

BCA

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. a) a client who eats a diet high in vitamins A and C b) a client with a peripheral vascular disorder c) a client who is taking corticosteroid drugs d) an older adult who is confined to bed e) a client who is obese f) a 10-year-old client with a surgical incision

BCDA

The nurse is performing pressure ulcer assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure ulcer? a) an older client with arthritis b) a newborn c) a critical care client d) a client with cardiovascular disease

C Various factors are assessed to predicate a client's risk for pressure ulcer development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains? a) A Penrose drain is a closed drainage system that is connected to an electronic suction device. b) A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. c) A Penrose drain promotes drainage passively into a dressing. d) A Penrose drain has a small bulblike collection chamber that is kept under negative pressure.

C A Penrose drain is an open drainage system that promotes drainage of fluid passively into a dressing. Additional drains include the Jackson-Pratt drain that has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

A nurse is caring for a client who has a pressure ulcer on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-blue (RYB) Wound Classification System, which of the following classifications should the nurse document? a) Yellow classification b) Red classification c) Black classification d) Unstageable

C A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound.

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? a) Gauze b) Hydrocolloid c) Transparent d) Bandage

C The nurse should use a transparent dressing to cover the IV insertion site because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage. A hydrocolloid dressing helps keep the wounds moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

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? a) period during which new cells fill and seal a wound b) physiologic defense immediately after the tissue injury c) period during which the wound undergoes changes and maturation d) process by which damaged cells recover and reestablish normal function

C The remodeling phase can be described as the period during which the wound undergoes changes and maturation. The remodeling phase follows the proliferative phase and may last for 6 months to 2 years. The inflammatory phase is the physiologic defense immediately after tissue injury. The proliferation phase is the period during which new cells fill and seal the wound. Resolution is the process by which damaged cells recover and reestablish normal function. This forms part of the proliferation phase.

Which action should the nurse perform when applying negative pressure wound therapy? a) Irrigate the wound thoroughly using normal saline and clean technique. b) Test the seal of the completed dressing by briefly attaching it to wall suction. c) Cut foam to the shape of the wound and place it in the wound. d) Increase the negative pressure setting until drainage is brisk.

C When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

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? a) "Allowing a scab to form would prevent us from observing the wound for signs of infection." b) "You may be correct. I will check with your primary health care provider." c) "Wounds heal better when a moist wound bed is maintained." d) "This wound is too large for a scab to form over it, so a moist dressing is the best alternative."

C A moist wound surface enhances the cellular migration necessary for tissue repair and healing.

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments? a) Implement nursing interventions for Altered Skin Integrity. b) Document the presence of a pressure ulcer and develop a care plan. c) Immediately report to the physician that the client has a pressure ulcer. d) Recognize that this is ischemia, followed by reactive hyperemia.

D

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? a) Tertiary intention b) Desiccation c) Primary intention d) Secondary intention

D

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) Apply moist dressing b) Debridement c) Gentle cleansing d) Wound irrigation

D

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? a) Perform the dressing change during mealtime to allow for distraction. b) Plan to administer a prescribed analgesic immediately prior to the dressing change. c) Perform the dressing change when the client is fatigued after physical therapy. d) Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change.

D

The nurse is discussing care of a client's wound that has nonviable tissue in the base with the wound care nurse. The wound care nurse recommends that the nurse utilizes a dressing that would promote autolytic debridement of the wound. Which of the following dressings should the nurse select? a) Wet to dry b) Negative wound pressure therapy c) Telfa d) Hydrocolloid

D

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? a) transparent films b) hydrogels c) alginates d) hydrocolloid dressings

D Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a) Antihypertensive drugs b) Potassium supplements c) Laxatives d) Corticosteroids

D Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing

Which best describes the third phase of the wound healing process: proliferative? a) the onset of vasoconstriction, platelet aggregation, and clot formation b) marked by vasodilation and phagocytosis as the body works to clean the wound c) the number of fibroblasts decreases, collagen synthesis is stabilized and collagen fibrils become increasingly organized, resulting in greater tensile strength of the wound d) epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization

D In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. The onset of vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing—hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibril become increasingly organized.

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply. a) The nurse applies moist cold to a client's eye for 40 minutes every 2 hours. b) The nurse instructs the client to lean or lie directly on the heating device. c) The nurse places a heating pad on a sprained wrist that is in the acute stage. d) The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. e) The nurse fills an ice bag with small pieces of ice to about two-thirds full. f) The nurse makes more frequent checks of the skin of an older adult using a heating pad.

DEF