Tissue Integrity

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.

"Very little scar tissue will form." "This is a simple reparative process." Your wound edges are right next to each other

The patient is advised to apply a suspension-type lotion to a dermatosis site. The nurse should advise the patient to apply the lotion how often to be effective?

Every 3 hours

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention

A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn?

moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

The nurse is performing a skin assessment on a bedbound client who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than

1 hr

A client with diabetes and peripheral neuropathy is being discharged from the hospital. What instruction should the nurse provide to decrease the risk for skin breakdown? Select all that apply.

Always wear socks and, preferably, shoes to protect the feet. Check the feet daily to look for any injuries. Use lotion on feet

An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?

Application of an ostomy pouch

A school-aged child is brought to the office of the camp nurse with a small, superficial burn (first-degree burn). Which action by the nurse would be most appropriate to take first?

Apply cold compresses to the area.

Which cleansing solution is the most effective for use in completing pin site care?

Chlorhexadine

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 nurse conducting a staff inservice on wound healing in older adults determines that the participants are understanding the information when they state that older adults may experience delayed wound healing due to which aging process? Select all that apply.

Decreased collagen synthesis Slower re-epithelialization Impaired wound contraction

The nurse is assessing a client for acute inflammation of a wound. Which symptom does the nurse attribute to the acute inflammatory response?

Edema

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

Fungi

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?

Inform the physician immediately.

When describing abdominal hernias to a group of nursing students, the instructor would identify which type as most common?

Inguinal

The instructor asks a group of nursing students to explain the function of the omentum. The students will respond based on which pathophysiologic principle?

It has substantial mobility and moves around in the peritoneal cavity with peristaltic movements.

Which procedure done for skin cancer conserves the most amount of normal tissue?

Mohs micrographic surgery

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply?

Moist sterile saline gauze

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

A client seeks medical care for a first-degree burn over the chest, back, face, and arms from sun exposure. Which should the nurse identify as the primary concern?

Pain management

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?

Place an ice pack.

The nurse is assessing the wound of a postoperative client. The client has a 6-inch abdominal wound that is well approximated and closed with surgical suture. The wound does not display any redness or drainage. The nurse would document the healing process as:

Primary intention

A few of the more experienced nurses are sitting around a lunch table discussing the changes they are seeing in their skin. Which of these would be considered normal age-related changes? Select all that apply.

Reduction in subcutaneous tissue., dry scaly skin

An injury with little exudate that can be treated with semipermeable or occlusive dressings are representative of which stage of pressure injury(ies)? Select all that apply.

Stage 2 and 3

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage 2 pressure ulcer

A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the incision is separating. What is the nurse's priority action?

Stop the staple removal, cover the incision, and report the findings to the physician.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply.

The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary. This is a severe burn and nerve endings have been destroyed

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

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?

Using normal saline solution to clean the ulcer and applying a protective dressing as necessary

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing?

Vitamin C

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?

at the base of the wound

An older adult client arrives to the health care provider's office complaining of a "sore" that won't heal on the lower leg. Upon assessment, the nurse finds thin, shiny, bluish brown pigmented desquamative skin. It is located medially over the lower leg. The nurse will educate the client that the usual treatment is:

compression therapy to help facilitate blood flow back to the vena cava.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound

dehisced First

The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage?

figure-of-eight turn

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

first intention

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

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?

serosanguinous

How does histamine release contribute to ulcer formation?

stimulates gastric acid secretion

The nurse is changing an occlusive dressing on a stage III pressure injury and notes the formation of new eschar in the wound bed. For what change in the wound care plan should the nurse advocate?

switching to using wet-to-dry dressings

Which client would likely benefit the most from hyperbaric oxygen therapy?

trauma client who developed Clostridium spp., an anaerobic bacterial infection in the femur