Week 5 Sherpath

Purulent yellow

infected

pale, soft, wrinkled

macerated

black, hard, dry

necrotic

Which response is likely when a patient who has a full-thickness wound receives a steroid?

Healing time will slow.

Greenish yellow

purulent

Bright red

sanguineous drainage

Pink to pale red

serosanguineous

clear and watery

serous

Which patient situations are of immediate concern?

shock hemorrhage eviscerated wound

Which action is taken for a patient receiving oxygen with a nasal cannula to prevent nasal passages from drying?

Humidifying the oxygen

Which action for skin hygiene would the nurse take for an obese patient who is immobile?

Keep skinfolds dry from perspiration.

Which intervention would the nurse implement for a patient with an open drain?

Keep the safety pin in place.

Which obesity factors contribute to a nonhealing wound?

Lack of blood vessels in adipose tissue Undue pressure on wound edges Decreased oxygen and nutrients to the wound

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)?

Monitor the patient's toes for impaired circulation.

Which hypotheses would the nurse develop for a patient post surgery for hip replacement who is receiving opioid pain medication while the patient's spouse is in the room?

impaired mobility risk for DVT risk for constipation

Which cues are relevant for an infected wound?

Positive culture growth Purulent drainage Induration around edges

Which overall mobility goal would the nurse select for a patient on bed rest?

Prevent complications of immobility

Which change is associated with aging of the skin?

Reduced insulation and cushioning, resulting in an increased risk for skin trauma and heat loss

Which response is a result of poor perfusion to the skin?

Reduced production of fibroblasts

Which cue alerts the nurse that a patient receiving cold therapy is improving?

Relief from muscle spasms

Which statement indicates the nurse has a correct understanding of a patient's pressure-reducing bed?

"The support surface may be foam or gel."

Which classifications are used to identify wounds?

- Cause - Depth - Contamination level - Healing time

Which characteristics of aging cause the skin to be fragile, loose, dry, and transparent?

- Loss of elastin - A decrease in the number of sweat glands - A smoothing of the layer of skin under the epidermis

Which features describe the subcutaneous layer of skin?

- Provides insulation to protect against both heat and cold - Cushions bony prominences and internal organs

What functions are associated with the skin?

- Transmits sensations of pain - Regulates body temperature - Forms an effective barrier against environmental hazards - Assists with the elimination of toxins and wastes from the body

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound?

- high protein diet - pt will transfer w/in 24 hrs -

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity?

- low albumin levels - immobility - stage 2 pressure injury

Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)?

- monitor of granulation tissue in the wound - avoid using NPWT for a pt w/ a cancerous wound - if a pt reports pain, switch from black to white foam - report drainage to HCP

Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage?

- notify HCP - take temp - check WBC

Which factors can directly cause the fibroblasts and collagen to be altered or ineffective in the proliferative phase of wound healing?

- prolonged decrease of O2 perfusion to skin - lack of protein - lack of Vit C - History of Diabetes

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound?

- repositioning the pt - reporting any changes in pt's skin integrity or condition - applying a nonsterile dressing for chronic wounds with an established treatment plan

Which processes occur in the proliferative phase of wound healing?

- stimulation of angiogenesis - creation of granulation tissue

After receiving report, the nurse would delegate which tasks to the unlicensed assistive personnel?

- turning a pt w/ a pressure injury - cleaning an incontinent patient of stool and urine

Which nutrients would need to be increased in the diet of a patient with full-thickness burns?

- zinc - copper - protein - Vit A - Vit B - Vit C

Which patient would the nurse see first after receiving report?

A patient with a profusely bleeding wound

Which patients must use an electric razor when shaving?

A patient with hemophilia A patient on an aspirin regimen A patient taking heparin

Which patient situation is an example of friction?

A patient's leg rubbing against the side rail of a bed

Which definition of a fistula is correct?

Abnormal connection between two internal organs

Which strategy would the nurse use to classify a burn?

According to the skin layer damaged

Which primary parameters are measured when using the Norton Scale?

Activity Mobility Mental State - Physical Condition - Continence

Which steps are involved in measuring wound undermining?

Administer pain medication. Laterally insert the cotton-tipped applicator into the widest section. Mark the area on the stick end of the applicator that is even with the edges of the skin. Measure the distance from the top of the applicator to the marked area.

The nurse would use which organization's guidelines to direct care for a patient's back wound?

Agency for Healthcare Research and Quality (AHRQ)

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair?

Allow the patient to dangle.

Which action would the nurse take to improve an immobile patient's nutritional intake?

Allow the patient to make food choices.

Which factors can place a patient at risk for a pale, dry wound?

Anemia Diabetes Vascular disease Nutritional deficiency

Which type of opening occurs in a patient who has an enterocutaneous fistula?

Between the skin and the intestine

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining?

Has a Braden Scale score that indicates a high risk for skin breakdown Develops a Stage 1 pressure injury on the buttocks Develops a Stage 2 pressure injury on the left hip

Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement?

Autolytic

Which cells join the epidermis and dermis and are arranged in a single layer?

Basal cells

Which function will be compromised if the dermis is injured?

Blood supply to the skin

Which evaluative cue would alert the nurse that a patient with a pressure injury is declining?

Braden Scale score was a 9 but is now an 8.

For which reason is it contraindicated for a patient with peripheral neuropathy or diabetes to soak the feet?

Can cause tissue drying and increase risk for infection

Which patient situation indicates that a sink bath is appropriate?

Can perform part of the sink bath independently

Which action must the nurse perform before a patient receives a shower?

Check the health care provider's prescription to determine if showering is safe.

Which items would the nurse obtain to initiate vacuum-assisted wound closure for a patient?

Clear adhesive drape Suction tubing Foam sponge Negative-pressure setting device

Which interpretation would the nurse make about a wound that is colonized?

Contains microorganisms on the surface of the wound only

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving?

Has a pulse oximetry reading of 94% when standing to brush teeth

Which question would the nurse ask to determine the patient's health history about skin integrity?

Has anyone in your family had a skin disorder?

Which patient scenario would prompt the nurse to question a prescription for cold therapy?

Has edema present

Which complication would the nurse identify for the health care provider in a patient whose surgical incision "popped" open and is draining fluid?

Dehiscence

Which components are likely damaged when the nurse chooses the hypothesis Impaired Skin Integrity for a patient?

Dermis and Epidermis

Which term would the nurse use to describe excessive moisture on the patient's skin?

Diaphoresis

Which finding is expected in a physical skin assessment?

Elastic skin turgor

Which cues would the nurse observe for a patient with an infected lateral malleolus wound?

Erythema noted on the superior portion of the wound Purulent, malodorous drainage Temperature of 102°F (38.9°C)

Which complication allows visceral organs to be exposed through an incision?

Evisceration

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat?

Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

Effleurage can effectively reduce which bodily functions?

HR, RR, Anxiety

Which cue is relevant for a patient who has a wound?

Having a low prealbumin level

Which hypothesis would the nurse select for a patient with a breakdown in the dermis from external forces?

Impaired Skin Integrity

Which actions would the nurse avoid when clipping the nails of a patient diagnosed with peripheral neuropathy and circulatory impairment?

Increasing circulation to the area prior to clipping Using the patient's own nail trimmer Massaging each digit prior to clipping

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair?

Initiate a fall prevention plan for the patient.

Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed?

Initiate a fall prevention plan for the patient.

Which characteristic accurately describes the dermis?

Is an area for sebaceous glands

Which statement regarding the skin is accurate?

It is closely linked to personal identity.

Which interpretation would the nurse make about a patient's wound culture that is positive?

It is infected.

Which parameters would the nurse assess when performing a focused wound assessment?

Location Drainage Wound bed Tunneling

Which term describes the last phase of wound healing?

Maturation

A patient who is scheduled for surgery has been prescribed nothing by mouth (NPO) yet wants to have her teeth brushed. Which item would the nurse use to brush the patient's teeth?

Moistened toothette

Which solution would the nurse obtain to clean a patient's arm wound?

Normal saline

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility?

Obtains two unlicensed assistive personnel to help

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle?

Open the window blinds during the day.

Which SMART (specific, measurable, assignable, relevant, time-based) outcomes would the nurse develop for a patient who is light-headed and fatigued and has feeble handgrip with reduced bone density?

Patient will brush teeth after breakfast with one person assisting. Patient will exercise joints at least twice per shift.

Which outcomes would the nurse develop for a patient experiencing weakness, cerebellum injury, and orthostatic hypotension?

Patient will not fall during hospitalization. Patient will not injure self during hospital stay.

Which expected outcome would the nurse select for a patient who has a hypothesis of Pressure Ulcer/Injury?

Patient's Braden Scale score will stay the same or increase within 72 hours.

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident?

Patient's wound will exhibit granulation tissue in the wound by 1 week.

Which type of massage is best for patients with deep muscle tension?

Petrissage

Which technique would the nurse use to turn a patient?

Position patient's body laterally at 30 degrees.

Which benefits are associated with the provision of oral care?

Prevents infections Reduces halitosis Removes plaque

Which primary objective does the proliferative phase of wound healing achieve?

Producing granulation tissue

Which phase of wound healing is characterized by a patient who reports that the bumpy and granular injured site "bleeds easily"?

Proliferative

Which overall goal would the nurse develop for a patient with a leg incision?

Promote complete healing of wound.

Which action by the nurse is priority when providing discharge teaching to a patient and spouse about wound care when the spouse is the primary caregiver?

Provide written instructions.

Which description regarding the subcutaneous skin layer is correct?

Provides a cushioning effect

Which benefits are associated with bathing and skin care?

Provides skin hydration Removes bacteria from the skin Reduces possibility of maceration Removes dead skin from the body

Which action would the nurse take when caring for a patient's Jackson-Pratt drain?

Reactivate the drain after emptying.

Which effect on the wound would likely occur if a patient with pressure injuries smoked?

Receives less oxygen

While assisting a patient with teeth brushing, the nurse notices the patient has difficulty grasping and maneuvering the toothbrush. Which action would the nurse take to further assist this patient?

Request a large-handled toothbrush.

Which hypothesis would the nurse develop for an immobile patient who has intact skin?

Risk for Impaired Skin Integrity

Which type of fluid would the nurse likely observe if the patient was hemorrhaging?

Sanguineous

Which patient situation is a medical emergency?

Shock A patient experiencing shock is a medical emergency because it indicates the patient is hemorrhaging internally or externally.

Which piece of equipment would the nurse likely obtain for a patient who has a prescription for therapy that is primarily heat only?

Sitz bath

Which factors may impact the development of pressure injuries or nonhealing wounds?

Smoking Diabetes Urinary incontinence

Which classification would the nurse use for staging a pressure injury that has a full-thickness wound and extends into the subcutaneous tissue, but not into the fascia, muscle, or bone?

Stage 3

beefy red, shiny, moist

granulated

Which actions would the nurse take for a patient who is immobile?

Suggest drinking at least 2000 mL during a 24-hour period. Encourage passive range-of-motion exercises. Place high-top tennis shoes on feet.

Which action would the nurse take for a patient with a hypothesis of Impaired Skin Integrity?

Suggest increasing fluid intake.

Which solution would the nurse select for a patient who has a hypothesis of Risk for Deep Vein Thrombosis?

TED hose

Which instruction would the nurse share with the patient about coughing techniques?

Take two deep breaths in and out to start.

Which information would the nurse share with a patient about wound healing by tertiary intention?

The wound will be closed later when the infection risk is reduced.

Which reasoning explains why a nurse measures wound size during an initial wound assessment?

To help assess progression of wound healing

Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with minimal drainage?

Transparent

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed?

Trapeze bar

Which parameters would the nurse include when charting about a patient's warm compress on the left leg?

Type of heat or cold therapy Equipment used for assessments of pt Time of application, length, frequency Any signs of infection at the site Type of drainage Pt concerns or reports of pain Interventions, including pt teaching If any adverse effects occur and treatment provided

Which categories can the nurse use to organize and link the patient's skin integrity cues?

Type of wound Type of wound bed tissue Unexpected assessment findings Unexpected laboratory findings

Which statement about ultraviolet light is accurate?

Ultraviolet light A (UVA) penetrates the dermis.

Which patient condition requires the nurse to pay special attention to the oral cavity given increased susceptibility to oral infections, dryness, and tissue damage?

Undergoing chemotherapy

Which techniques would the nurse use to troubleshoot issues with patients' dressings?

Use an abdominal binder to help a patient who has an abdominal wound to cough. Use Montgomery straps for a patient who needs frequent dressing changes. Use a splint to help a patient who has an abdominal incision to deep breathe.

A nurse is instructing a newly blind patient how to clean the eyes. Which instruction would the nurse provide?

Use plain water and wipe from the inner canthus to the outer canthus.

Which action would the nurse take when irrigating a patient's abdominal wound?

Use sterile technique.

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility?

Use the incentive spirometer 5 to 12 times every 1 to 2 hours. Deep breathe 10 times every hour. Cough two to three times every 2 hours. Move each joint three to five times during range-of-motion exercises.

Which wound is classified as a closed wound?

bruise

Secondary intention healing

healing is from bottom and sides of wound

Which benefit does a sitz bath provide for a new mother?

decreases swelling

teritary intention

delay between injury and closure

Primary intention healing

edges are approximated

Which food would the nurse suggest the patient consume to increase zinc in the diet for wound healing?

fish

Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of wound drainage?

foam

Patients with which conditions should avoid soaking their feet?

peripheral neuropathy diabetes sensory deficits

For which patients is pediculicidal shampoo contraindicated?

pregnant women, young children, and pts with history of seizures

Which interventions would the nurse implement for a patient with lower extremity Paralysis?

turn every 2 hrs arrange for a special bed perform ROM exercises at least 2x daily