Skin Integrity & Wound Healing

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 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.

When applying an external heating pad, which prescription from the health care provider would the nurse question? - Leave heating pad on for 40 to 45 minutes, then off for 2 hours. - Assess site frequently during application of the heating pad. - Use gauze to secure the heating pad to the site of application. - Maintain the temperature between 105°F to 109°F (40.5°C to 43°C).

Leave heating pad on for 40 to 45 minutes, then off for 2 hours. Explanation: The nurse should question the prescription to leave the heating pad on for 40 to 45 minutes, because this is too long and could cause a rebound phenomenon. Using heat for more than 20 to 30 minutes can result in tissue congestion, vasoconstriction, and increases the risk of tissue damage. All other prescriptions are recommended guidelines for use of a heating pad.

Which is not considered a skin appendage? - Hair - Connective tissue - Sebaceous gland - Eccrine sweat glands

Connective Tissue

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

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

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 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.

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

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.

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?

Incision Explanation: An incision is a clean separation of skin and tissue with smooth, even edges.

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

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?

hemostasis phase

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."

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply. - "Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." - "Most pressure injuries occur over the trochanter and calcaneus." - "Generally, a pressure injury will not appear within the first 2 days in a person who has not moved for an extended period of time." - "The major predisposing factor for a pressure injury is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues." - "The skin can tolerate considerable pressure without cell death, but for short periods only." - "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."

"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." - "The skin can tolerate considerable pressure without cell death, but for short periods only." - "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."

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."

he 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."

The nurse is using the Braden Scale to determine a client's risk for pressure injuries. What criteria will the nurse assess? Select all that apply - sensory perception - nutrition - age - ability - friction

- sensory perception - nutrition - ability - friction

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 passive drainage into a dressing. - A Penrose drain is a closed drainage system that is connected to an electronic suction device. - A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. - A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

A Penrose drain promotes passive drainage into a dressing.

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

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

An obese woman with a history of type 1 diabetes

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them?

Apply moist saline compresses to loosen crusts before attempting to remove the staples.

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?

As a stage I pressure injury

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. -Administer the prescribed analgesic. -Notify the health care provider of the pain. -Document the pain and vital signs.

Assess the client's wound and vital signs.

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?

Braden Scale

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

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.

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

The occupational nurse is caring for a construction site employee who stepped on a nail. The nail penetrated the sole of the boot and injured the worker's foot. What type of safety guidelines would the nurse recommend related to puncture wounds? Select all that apply.

Current tetanus vaccine Regularly inspect site to eliminate hazards Wear designate safety boots

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 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

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 best action by the nurse at this time?

Discontinue the therapy and assess the client.

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

Every 48 to 72 hours

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 Explanation: Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

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.

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.

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

The nurse is helping a confused client with a large leg wound order dinner. Which food item is mostappropriate for the nurse to select to promote wound healing?

Fish Explanation: To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing.

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.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? - Local capillary pressure must be lower than external pressure. - The heart must be able to pump adequately. - The volume of circulating blood must be sufficient. - Arteries and veins must be patent and functioning well.

Local capillary pressure must be lower than external pressure.

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

Removing dead or infected tissue to promote wound healing

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.

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 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

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

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?

Transparent Explanation: 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

T OR F: A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

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

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

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:

a rash related to a yeast infection.

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

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention (Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.)?

a surgical incision with sutured approximated edges

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

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 full-thickness or third-degree burn develops a leathery covering called a(an):

eschar.

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing?

hydrocolloid dressing Explanation: 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.

The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?

oblique

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: (what degree and describe)

second degree or partial thickness

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 is this?

secondary intention Explanation: Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue...

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 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 Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink.

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

to apply sunscreen when exposed to ultraviolet rays.

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 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."

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. Explanation: A fistula is an abnormal tubelike passageway that forms from one organ to outside the body.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?

stage IV