Skin Integrity & Wound Healing

B. Secondary intention Rationale: This wound is healed by secondary intention, as there is granulation and epithelial tissue in the wound bed. The wound is healing from the inside out.

The nurse is documenting wound progress for a client and notes that there is pearly pink tissue in the wound bed as well as granulation tissue. It has decreased in size over the past 4 weeks. Which type of healing should the nurse document is occurring? A. Primary intention B. Secondary intention C. Tertiary intention D. Inflammatory phase

C. Laceration Rationale: The skin or mucous membranes are torn open, resulting in a wound with jagged margins

A client is admitted to the Emergency Department after falling off an embankment. Since the client was wearing shorts, there are deep cuts and tears in the skin. This wound is best described as: A. Abrasion B. Macerated C. Laceration D. Eschar

B. "I'll wash my hands before I remove the old dressing and again before putting on new ones." Rationale: It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressing.

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indicator that the client understands medical asepsis? A. "I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll wash my hands before I remove the old dressing and again before putting on new ones." C. "I'll need to take a pain pill 30 minutes before I change the dressing." D. "I'll wear sterile gloves when I apply the new dressing."

A & D A. Correct: Cover the wound with sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. D. Correct: This position minimizes pressure on the abdominal area.

A client who had abdominal surgery 24-hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (select all that apply) A. cover the area with saline soaked sterile dressings B. apply an abdominal binder snugly around the abdomen C. use sterile gauze to apply gentle pressure to the exposed tissue D. position the client supine with the hips and knees bent E. offer the client a warm beverage (herbal tea)

A & E A. Correct: Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. E: Correct: Open burn areas heal by secondary intention, which is the process for wounds tat have tissue loss and widely separated edges.

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply) A. stage 3 pressure ulcer B. sutured surgical incision C. casted bone fracture D. laceration sealed with adhesive E. open burn area

B, C, & D B. Correct: Diabetes mellitus is a chronic illness that places additional stress on the body's healing mechanism. C. Correct: Hgb is essential for oxygen delivery to healing tissues, and this client's Hgb level is low. D. Correct: A BMI of 17.1 indicates that the client is underweight and, therefore, malnourished. Deficiencies in essential nutrients delay wound healing

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their Hgb is 12 g/dl and BMI is 17.1. The incision is approximated and free of redness with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply) A. extremes in age B. chronic illness C. low hemoglobin D. malnutrition E. poor wound service

A & D A. Correct: Slightly elevates the head of the client's bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. D. Correct: Have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas.

A nurse is caring for a client who is at risk for developing a pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (select all that apply) A. keep the head of the bed elevated 30 degrees B. massage the clients bony prominences frequently C. apply cornstarch liberally to the skin after bathing D. have the client sit on a gel cushion when in a chair E. reposition the client at least every 3 hr while in bed

A, B, & C A. Correct: Expect the client to have a pain and tenderness at the wound site with and incisional infection. B. Correct: Expect the client to have fever and chills with an incisional infection C. Correct: Expect the client to have reddened or inflamed wound edges with an incisional infection

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply) A. increase in incisional pain B. fever and chills C. reddened wound edges D. increased in serosanguineous drainage E. decrease in thirst

B. Social worker Rationale: The nurse should recommend a referral to a social worker when a client will require additional services, such as home health care, oxygen therapy, hospice care, or wound care.

A nurse is planning care for a client who has COPD, requires continuous oxygen therapy, and is being discharged to return home. Which of the following referrals should the nurse recommend? A. Spiritual advisor B. Social worker C. Physical therapist D. Occupational therapist

A. Vitamin C & zinc Rationale: The client's body needs both vitamin C and zinc to fight a wound infection. The client should receive a multivitamin and a mineral supplement of both these supplements. In addition, vitamin E supplements also are needed to promote skin and wound healing.

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet. A. Vitamin C & zinc B. Vitamin D C. Vitamin K & iron D. Calcium

C. Check the client's pain level Rationale: The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous steps, beginning with an assessment or data collection

A nurse is planning for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

A. Arterial ulcer

A painful complication in the patient with peripheral arterial disease. Typically, the ulcer is small and round, with a "punched out" appearance and well-defined borders. Ulcers develop on the toes (often the great toe), between the toes, or on the upper aspect of the foot. With prolonged occlusion, the toes can become gangrenous. A. Arterial ulcer B. Venous stasis ulcer C. Diabetic pressure ulcer

A. Inspect the wound for bleeding. Rationale: After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to A. Inspect the wound for bleeding. B. Inspect the wound for foreign bodies. C. Determine the size of the wound. D. Determine the need for a tetanus antitoxin injection.

A. I Rationale: Localized area of intact skin with nonblanchable redness (does not become pale under applied light pressure), usually over a bony prominence; but not maroon or purple discoloration. The area may be painful, firm, soft, or warmer or cooler as compared with adjacent tissue. Discoloration will remain for >30 minutes after pressure is relieved.

The image illustrated is an example of which type of pressure injury? A. I B. II C. III D. IV E. Deep Tissue F. Unstageable

B. II Rationale: Involves partial-thickness loss of dermis. Stage 2 pressure injuries are open but shallow and with a red pink wound bed. There is no slough (tan, yellow, gray, green, or brown necrotic tissue). May also be an intact or open/ruptured serum-filled blister; or a shiny or dry shallow ulcer without slough or bruising.

The image illustrated is an example of which type of pressure injury? A. I B. II C. III D. IV E. Deep Tissue F. Unstageable

C. III Rationale: A deep crater characterized by full-thickness skin loss with damage or necrosis of subcutaneous tissue. Adipose tissue is visible. May extend down to, but not through, underlying fascia. Undermining (deeper-level damage under boggy superficial layers) of adjacent tissue may be present. Bone/tendon is not visible or directly palpable.

The image illustrated is an example of which type of pressure injury? A. I B. II C. III D. IV E. Deep Tissue F. Unstageable

D. IV Rationale: Involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures. Exposed bone, tendon, or cartilage is visible or directly palpable. Slough or eschar (tan, black, or brown leathery necrotic tissue) may be present. Ebole (rolled edges), undermining and sinus tracts (blind tracts underneath the epidermis) are common.

The image illustrated is an example of which type of pressure injury? A. I B. II C. III D. IV E. Deep Tissue F. Unstageable

E. Deep Tissue Rationale: An area of skin that is intact but discolored. It might be purplish or deep red, painful, boggy, or have a blister. Pain and temperature change often come before skin color changes.

The image illustrated is an example of which type of pressure injury? A. I B. II C. III D. IV E. Deep Tissue F. Unstageable

F. Unstageable Rationale: Involves full-thickness skin loss. The base of the wound is obscured by slough (tan, yellow, gray, green, or brown necrotic tissue) or eschar (tan, black, or brown leathery necrotic tissue).

The image illustrated is an example of which type of pressure injury? A. I B. II C. III D. IV E. Deep Tissue F. Unstageable

A. Serous Exudate Rationale: Serous exudate is thin, watery, and clear fluid

The image shown is illustrating what type of exudate? A. Serous Exudate B. Sanguineous Exudate C. Serosanguineous Drainage D. Purosanguineous Exudate E. Purulent Exudate

B. Sanguineous Exudate Rationale: Sanguineous exudate has a bright, red fresh blood (may be hemorrhagic)

The image shown is illustrating what type of exudate? A. Serous Exudate B. Sanguineous Exudate C. Serosanguineous Drainage D. Purosanguineous Exudate E. Purulent Exudate

C. Serosanguineous Drainage Rationale: Serosanuineous is thin and watery w/ light red or pink hue

The image shown is illustrating what type of exudate? A. Serous Exudate B. Sanguineous Exudate C. Serosanguineous Drainage D. Purosanguineous Exudate E. Purulent Exudate

E. Purulent Exudate Rationale: purulent exudate is thick, opaque, & odorous. Builds up from infection

The image shown is illustrating what type of exudate? A. Serous Exudate B. Sanguineous Exudate C. Serosanguineous Drainage D. Purosanguineous Exudate E. Purulent Exudate

B. Registered dietitian. Rationale: Assessment and a plan for the patient to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote wound healing. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can be consulted when the patient has a discharge need. A chaplain can be consulted when the patient has a spiritual need.

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a A. Respiratory therapist. B. Registered dietitian. C. Chaplain. D. Case manager.

D. Serosanguineous Rationale: Serosanguineous drainage is a mixture of serous and sanguineous drainage that is light red or pink-tinged

The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record? A. Serous B. Purulent C. Sanguineous D. Serosanguineous

C. Interference with circulation Rationale: With open-pore reticulated polyurethane foam therapy, a specialized pump is used to create a negative pressure environment. The wound is packed with foam or gauze dressing and a vacuum is created. The subatmospheric pressure reduces edema from swollen tissues, promotes granulation tissue formation, and removes exudate and infectious material. When pressure is applied, a circumferential dressing may interfere with circulation if wrapped too tightly.

The nurse avoids placing a dressing that wraps around an extremity to prevent what complication? A. Impaired healing B. Discomfort and skin trauma C. Interference with circulation D. Skin breakdown prevention

A. Impaired healing Rationale: Adhesive skin closures are used frequently to keep surgical incisions well approximated. They may be used in conjunction with staples or sutures or following early staple/suture removal. Closures may be used to approximate the edges of lacerations or skin tears. Skin preparation products help to secure the skin closures so they adhere more tightly. This product should not come in contact with the incision because this may impair healing.

The nurse avoids skin preparation product from contacting the wound to prevent what complication? A. Impaired healing B. Transfer of microorganisms C. Flow of contaminated solution D. Skin breakdown prevention

A. Ineffective tissue perfusion Rationale: The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing diagnosis.

The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? A. Ineffective tissue perfusion B. Risk for infection C. Imbalanced nutrition: less than body requirements D. Acute pain

C. Flow of contaminated solution Rationale: When obtaining a culture from a wound with a swab, the nurse must first irrigate the wound. Irrigating from top to bottom prevents flow of contaminated solution over the cleansed area. After the wound has been irrigated, a culture of a red, granulated area can be obtained by pressing the swab against the granulating areas with sufficient pressure to express fluid from the wound tissue and rotate the swab.

The nurse irrigates top to bottom to prevent what complication? A. Impaired healing B. Transfer of microorganisms C. Flow of contaminated solution D. Skin breakdown prevention

B. II Rationale: This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage A. I. B. II. C. III. D. IV.

A & C Rationale: - A client with a fever is sweating and producing excess moisture that leads to skin maceration - Urinary incontinence if moisture that can cause skin moisture. This contributes to skin maceration.

The nurse is assessing the skin of a client and notes the area around the buttocks is reddened and macerated. Which factors may have contributed to this finding? Select all that apply. A. Fever B. Nausea and vomiting C. Urinary incontinence D. Shearing and friction E. Continuous pressure

B. Provide analgesic medication as ordered. Rationale: Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient's ability to increase mobility.

The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? A. Encourage the patient to sit up in the chair. B. Provide analgesic medication as ordered. C. Explain the risks of immobility to the patient. D. Turn the patient every 3 hours while in bed.

B. Provide analgesic medications as ordered. Rationale: Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure.

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? A. Don sterile gloves. B. Provide analgesic medications as ordered. C. Avoid accidentally removing the drain. D. Gather supplies

B. Call the physician; a blockage is present in the tubing. Rationale: Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step? A. Remove the drain; a drain is no longer needed. B. Call the physician; a blockage is present in the tubing. C. Call the charge nurse to look at the drain. D. As long as the evacuator is compressed, do nothing.

D. Primary intention. Rationale: A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by A. Tertiary intention. B. Secondary intention. C. Partial-thickness repair. D. Primary intention.

A. Gentle cleaners and thorough drying of the skin Rationale: Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown.

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? A. Gentle cleaners and thorough drying of the skin B. Absorbent pads and garments C. Positioning with use of pillows D. Therapeutic beds and mattresses

C. Less than 2 hours Rationale: When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? A. At least 3 hours B. Not longer than 30 minutes C. Less than 2 hours D. As long as the patient remains comfortable

C. Granulation Rationale: Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? A. Eschar B. Slough C. Granulation D. Purulent drainage

C. Irrigate with hydrogen peroxide. Rationale: Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.

The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? A. Use a low-air-loss therapy unit. B. Consult a dietitian. C. Irrigate with hydrogen peroxide. D. Utilize hydrogel dressing.

A. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. Rationale: The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.

The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? A. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. B. Notify the charge nurse about the change in status and the potential for infection. C. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). D. Notify the wound care nurse about the change in status and the potential for infection.

A. 4 Rationale: A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry.

The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). A. 4 B. 2 C. 1 D. 7

C. Débridement of the wound. Rationale: Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes A. Monitoring of the wound. B. Irrigation of the wound. C. Débridement of the wound. D. Management of drainage.

C. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. Rationale: Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection; also, this is an intervention, not a goal for this diagnosis. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are interventions, not goals or outcomes for this nursing diagnosis.

The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient? A. The patient's family will demonstrate specific care of the wound site. B. The patient will state what to look for with regard to an infection. C. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. D. The patient's family members will wash their hands when visiting the patient.

C. Encourage thorough handwashing of all individuals caring for the patient. Rationale: The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does not relate to the risk of infection. If the patient will be discharged before the wound is healed, the family will certainly need education on how to care for the patient. Teaching the family how to manage the odor associated with a wound is certainly important, but these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process.

The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? A. Teach the family how to manage the odor associated with the wound. B. Discuss with the family how to prepare for care of the patient in the home. C. Encourage thorough handwashing of all individuals caring for the patient. D. Encourage increased quantities of carbohydrates and fats.

C. Impaired skin integrity Rationale: After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? A. Readiness for enhanced nutrition B. Impaired physical mobility C. Impaired skin integrity D. Chronic pain

C. Rationale: Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and remodeling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges approximated. Wound closure is delayed until risk of infection is resolved.

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of A. Primary intention. B. Partial-thickness wound repair. C. Full-thickness wound repair. D. Tertiary intention.

A, C, D, F Rationale: Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and decreases the production of proinflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing.

The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) A. Nutrition B. Evisceration C. Tissue perfusion D. Infection E. Hemorrhage F. Age

A, D, & E

The nurse is cleaning a wound using a wet-to-damp dressing, making sure to clean each new section with a new piece of gauze. What should the nurse be assessing for during the wound cleaning? Select all that apply. A. Exudate B. Client's thirst level C. Internal bleeding D. Odor E. Type of tissue present

C. Cleansing in a direction from the least contaminated area Rationale: Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.

The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? A. Allowing the solution to flow from the most contaminated to the least contaminated B. Scrubbing vigorously when applying solutions to the skin C. Cleansing in a direction from the least contaminated area D. Utilizing clean gauge and clean gloves to cleanse a site

C. Protein. Rationale: Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased A. Fat. B. Carbohydrates. C. Protein. D. Vitamin E.

D. Halogen light Rationale: When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first item used.

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? A. Cotton-tipped applicator B. Disposable measuring tape C. Sterile gloves D. Halogen light

C. 20 Rationale: With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20.

The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient's Braden scale total score? A. 15 B. 17 C. 20 D. 23

C. "I am ready for my bath and linen change as soon as possible." Rationale: The patient's psychological response to any wound is part of the nurse's assessment. Body image changes can influence self-concept. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens gives you a clue that he or she may be concerned about the smell in the room. The patient stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.

The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? A. "I think I will be ready to go home early next week." B. "I am so weak and tired, I want to feel better." C. "I am ready for my bath and linen change as soon as possible." D. "I am hoping there will be something good for dinner tonight."

C. Sterile cotton-tipped applicator

The nurse is measuring the depth of a client's wound. What piece of equipment should she use to make this measurement? A. Sterile ruler B. Sterile string C. Sterile cotton-tipped applicator D. Sterile vernier caliper

D. Maceration

The nurse is packing a wound during a wet-to-damp dressing change. She avoids applying the moist dressing to the surrounding tissue to prevent what complication? A. Pressure injury B. External bleeding C. Fistula D. Maceration

A. Apply Montgomery straps. Rationale: Montgomery straps can be used to hold the dressing in place. It does not require frequent removal of tape and is less irritating to the skin.

The nurse is providing frequent dressing changes to an abdominal wound due to large amounts of drainage. The repeated use of tape is irritating the skin. Which intervention would be the best option for the nurse to use to alleviate the problem? A. Apply Montgomery straps. B. Leave the wound open to air. C. Decrease the dressing change frequency. D. Change to a different brand of adhesive tape.

A. I

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage A. I. B. II. C. III. D. IV.

A. I Rationle: Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage A. I. B. II. C. III. D. IV.

B. Applying compression stockings Rationale: The student nurse should not apply compression stockings to the lower extremities of a client with an artierial ulcer. This will further compromise blood flow and can lead to tissue necrosis.

The nurse is supervising a student nurse who is managing the care of a client who has lower extremity edema related to an arterial skin ulcer. Which action made by the nursing student requires correction? A. Elevating the lower extremity B. Applying compression stockings C. Instructing about smoking cessation D. Administering pain medications before dressing change

B, D, E, F Rationale: Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.

The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.) A. Ask whether patient's expectations are being met. B. Prevent injury to the skin and tissues. C. Obtain the patient's perception of interventions. D. Reduce injury to the skin. E. Reduce injury to the underlying tissues. F. Restore skin integrity.

B. Alteration in level of consciousness Rationale: Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include: A. A diet low in calories and fat B. Alteration in level of consciousness C. Shortness of breath D. Muscular pain

B. Transfer of microorganisms Rationale: When cleaning a wound using a wet-to-damp dressing, the nurse must discard used gauze in a biohazard receptacle and clean each new section with a new piece of gauze. Each pass removes surface bacteria and exudate and prevents transfer of microorganisms from the skin to the wound. During this process, the nurse should be assessing closely for the type of tissue present, exudate, and odor to determine the most effective treatment plan.

The nurse uses a new piece of gauze with each wiping pass to prevent what complication? A. Impaired healing B. Transfer of microorganisms C. Edema D. Skin breakdown prevention

B. Discomfort & skin trauma Rationale: The push-pull method of dry dressing removal helps prevent skin stripping from the adhesive and reduces discomfort and skin trauma as you remove the tape. If the client's skin is especially sensitive or tears easily, use an adhesive remover to loosen the tape and adhesive. Apply a skin protectant prior to the reapplication of tape.

The nurse uses the pull-push method to prevent what complication? A. Interference with circulation B. Discomfort & skin trauma C. Edema D. Skin breakdown prevention

C. Edema Rationale: When wrapping limbs and applying gauze dressings, the nurse should work from peripheral to central (or distal to proximal) to wrap the gauze to improve venous return and prevent edema.

The nurse works from peripheral to central to prevent what possible complication? A. Interference with circulation B. Blood flow restriction C. Edema D. Skin breakdown prevention

A, C, D, & E

The nurse's documentation of a wound states, "Round stasis ulcer on right ankle, no tunneling. Clear serous drainage present. Dry dressing applied." What additional documentation is needed? Select all that apply. A. Skin around the wound B. Activity level C. Pain and nutritional status D. Size E. Condition of wound bed

D. 23 Rationale: The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? A. 12 B. 13 C. 20 D. 23

C. Healing stage III pressure ulcer Rationale: When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words "healing stage." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? A. Stage I pressure ulcer B. Healing stage II pressure ulcer C. Healing stage III pressure ulcer D. Stage III pressure ulcer

B. Venous stasis ulcer

Ulcer caused by venous insufficiency and stasis of venous blood; usually forms near the ankle A. Arterial ulcer B. Venous stasis ulcer C. Diabetic pressure ulcer

D. Skin breakdown prevention Rationale: Skin prep, when applied to a wound prior to the application of a dressing or adhesive, helps protect the intact skin and prevent breakdown. It should be used with each dressing change unless contraindicated.

What is the purpose of the application of skin prep prior to a dressing application? A. Impaired healing B. Transfer of microorganisms C. Flow of contaminated solution D. Skin breakdown prevention

A. A 55-year-old obese female who underwent an abdominal hysterectomy Rationale: The client is obese and underwent abdominal surgery, which places her at high risk for wound dehiscence.

Which client is at highest risk for wound dehiscence? A. A 55-year-old obese female who underwent an abdominal hysterectomy B. A 75-year-old thin male who underwent a total hip replacement after a fall C. A 20-year-old thin female who underwent an emergency appendectomy D. A 40-year-old obese male who underwent back surgery for a herniated disk

A, B, C Rationale: - Venous stasis ulcers have irregular wound edges - The wound bed of a venous stasis ulcer is usually beefy red or ruddy in color - The area around the periwound skin is reddened or edematous

Which findings would the nurse expect to find when performing wound care for a client with a venous stasis ulcer? Select all that apply. A. Irregular wound edges B. Wound bed beefy red C. Periwound area reddened D. Pain noted with ambulation E. Loss of hair to the periwound area

A, B, D, & F Rationale: It is essential to document the location of the wound in the medical record. This communicates information to the next nurse to provide continuity of care. The nurse should also measure wounds a minimum of once per week to determine wound progress. The nurse would need to document the presence of undermining or tunneling in the wound bed. The nurse should document the color, consistency, and odor of the drainage.

Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of a client? Select all that apply. A. Location of the wound B. Length, width, and depth C. Nutritional status of the client D. Presence of undermining or tunneling E. Number and type of dressing supplies used F. Drainage amount, color, consistency, and odor

D. Scarring can be severe. Rationale: A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.

Which nursing observation would indicate that a wound healed by secondary intention? A. Minimal scar tissue B. Minimal loss of tissue function C. Permanent dark redness at site D. Scarring can be severe.

B. The patient has fecal incontinence. Rationale: The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? A. The patient ate two thirds of breakfast. B. The patient has fecal incontinence. C. The patient has a raised red rash on the right shin. D. The patient's capillary refill is less than 2 seconds.

A. Complaint by patient that something has given way -- reporting a tear at the site Rationale: Occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? A. Complaint by patient that something has given way -- reporting a tear at the site B. Protrusion of visceral organs through a wound opening C. Chronic drainage of fluid through the incision site D. Drainage that is odorous and purulent

B. Blood flow restriction Rationale: When packing a wound during a wet-to-damp dressing change, the nurse should lay the loosened gauze into the wound one layer at a time. The gauze should not be tightly packed, as this restricts blood flow to the tissue. The nurse should also avoid applying the moist dressing to the surrounding tissue to prevent maceration.

Why should the nurse prevent packing the gauze tightly into the wound? A. Interference with circulation B. Blood flow restriction C. Flow of contaminated solution D. Skin breakdown prevention

B. Subcutaneous layer (brown fat); preterm Rationale: The subcutaneous layer (brown fat) and sweat glands are not fully developed, especially for preterm infants. As a result, in the first few weeks of life thermoregulation is inadequate, and the infant must be swaddled to maintain body heat

The ______________ and sweat glands are not fully developed, especially for _______ infants A. Epidermal layer; full-term B. Subcutaneous layer (brown fat); preterm C. Dermal layer; preterm D. Subcutaneous layer (white fat); full-term

A, B, C, & D

An older adult is admitted to the care center for a skin assessment. What areas would the nurse assess using the Braden Scale for Predicting Pressure Sore Risk? Select all that apply. A. Friction and shear B. Moisture C. Activity D. Sensory perception E. Fluid status

D. The incision has a mass, bluish in color. Rationale: A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.

The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? A. The incision site has started to itch. B. The incision site is approximated. C. The patient has pain at the incision site. D. The incision has a mass, bluish in color.

D. Laceration Rationale: A laceration is a cut in the skin and mucous membranes are torn open. It leaves a cut with jagged edges.

A client presents to the clinic after falling in a parking lot and sustaining an injury. There is a break in the skin with jagged edges. There is no evidence of foreign debris in the wound. As the nurse documents the wound care, which term would the nurse use in the health record? A. Abscess B. Incision C. Crushing D. Laceration

A. Check the JP drain tubing for kinks. Rationale: As there is no drainage in the JP bulb, but all around the dressing, there is an occlusion somewhere. The nurse's first intervention should be to check the JP drain tubing for kinks.

A client reports to the nurse that there is drainage leaking around the Jackson-Pratt (JP) drain. The nurse notices the JP drain bulb is empty and the dressing is saturated with serosanguineous drainage. What should the nurse do first? A. Check the JP drain tubing for kinks. B. Compress the bulb and close the lid. C. Remove the JP drain from the abdomen. D. Notify the primary health-care provider.

C. Diabetic pressure ulcer

Narrowing of the arteries leads to reduced oxygenation to the feet, resulting in delayed wound healing and tissue necrosis. A. Arterial ulcer B. Venous stasis ulcer C. Diabetic pressure ulcer

B. Clean-contaminated wounds

These are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered: A. Clean wounds B. Clean-contaminated wounds C. Contaminated wounds D. Dirty or infected wounds