PrepU Skin and Wounds

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?" "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?"

"Do you experience incontinence?" This is excessive moisture (maceration) which is bad for skin

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 should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy." "I will put a layer of cloth between my skin and the ice pack." "I can let this stay on my ankle an hour at a time."

"I will put a layer of cloth between my skin and the ice pack."

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." "This is a complex reparative process." "The margins of your wound are not in direct contact." "The surgeon will leave your wound open intentionally for a period of time."

"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." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "As soon as the infection clears, your surgeon will staple the wound closed."

"Your wound will heal slowly as granulation tissue forms and fills the wound."

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Allow the wound and intestinal contents to remain open to air. Apply saline solution-moistened gauze over the protruding area. Pack the wound with gauze pads and a dry sterile dressing. Inform the client that this is an expected occurrence and not to worry.

Apply saline solution-moistened gauze over the protruding area.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Use clean technique to clean the wound. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Clean the wound from the top to the bottom and from the center to outside. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

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

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? Infection of the wound Herniation of the wound Dehiscence of the wound Evisceration of the viscera

Dehiscence of the wound

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 Maceration Necrosis Evisceration

Desiccation

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? Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Utilize the culture swab to obtain cultures from multiple sites. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Carefully pick the crusts off the sutures with the forceps before removing them. Do not attempt to remove the sutures because the wound needs more time to heal.

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

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? If there is contamination of dirt and debris The event leading up to the trauma Staging the wound for assessment The status of the client's tetanus immunization

The status of the client's tetanus immunization

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon applying sterile dressings with normal saline over the protruding organs and tissue assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound

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 incision avulsion puncture

contusion

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

dehiscence.

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 as an indication of infection? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color This is an infection!

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 that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound? hemostasis inflammatory phase proliferation phase maturation phase

proliferation phase

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? stage I stage II stage III stage IV

stage II