PrepU Skin Integrity and Wound Care

The nurse is taking care of a client 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."

Which teaching will the nurse include when teaching a client about a Jackson-Pratt drain?

"It provides a way to remove drainage and blood from the surgical wound."

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?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

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."

What is purulent drainage?

1) A sign of infection. 2) It's a white, yellow, or brown fluid and might be slightly thick in texture 3)May have odor

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client?

1) Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. 2) Change the dressing midway between meals. 3) Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound.

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity?

Clean perineal area daily but do not bathe full body on a daily basis

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.

Which is not considered a skin appendage?

Connective tissue

The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus

How should a nurse remove sutures from a client's traumatic wound that are encrusted with blood and difficult to remove?

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

When collecting wound culture has been ordered for a client whose hand wound is showing signs of infection, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

A pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. What stage is this?

STAGE 2

A pressure ulcer that is very red and surrounded by blisters is in which stage?

STYAGE 2

What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?

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.

Which implement should the nurse use to measure the depth of a tunneled wound accurately?

a sterile, flexible applicator moistened with saline

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

What type of dressing is occlusive,limits exchange of oxygen between wound and environment, provides minimal absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days?

hydrocolloid

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 purpose for a T-tube drain is..?

to provide drainage for bile.

What type of dressing should the nurse use to cover the IV insertion site?

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