ADN quiz 2 chapter 26

A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply.

"It may take longer for an older adult to heal." "Consider having a home health aide to assist with bathing and personal care." "Older adults with lots of sun exposure may experience delayed healing."

As a part of the senior citizen health program, the community health nurse arranges a free skin screening for the older adults. Which of the following would the nurse find when assessing the skin of older adult clients?

Liver spots

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

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

stage III

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside.

Which is not considered a skin appendage?

Connective tissue

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 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 client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue

A nurse uses an open drain to drain the blood and drainage from a client's wound. The nurse knows that an open drain functions in which way?

drainage occurs passively by gravity and capillary action

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

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

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

Apply saline solution-moistened gauze over the protruding area.

The nurse is preparing to irrigate a client's abdominal wound following wound dehiscence. Arrange the presented nursing activities in the correct order. Use all options.

Discuss the procedure with the client and assess client knowledge. Gather equipment required for a dressing change. Drape the client to expose the area of the wound. Position the client to facilitate filling the wound cavity with solution. Open and prepare supplies following the principles of surgical asepsis. Don gloves and other personal protective equipment. Fill the syringe with solution, and instill it into the wound. Dry the skin surrounding the wound.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

The nurse works outward from the wound in lines parallel to it.

A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe the client's wound?

a clean separation of skin and tissue with smooth, even edges

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:

a laceration.

Which processes are responsible for restoring integrity of the skin and damaged tissues in the care of a client with an open wound? Select all that apply.

scar formation regeneration resolution

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of pressure injuries. What is the name given to the factor responsible for this risk?

shearing force

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 assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?

white blood cells, debris, bacteria

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?

"That is necrotic tissue, which must be removed to promote healing."

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

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

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

The 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 older adult client reports back pain, and an aquathermia heating pad has been prescribed for comfort. What action(s) will the nurse perform to provide a safe application of heat therapy for this client? Select all that apply.

Assess the client's skin prior to the application of heat. Ensure that the aquathermia unit contains water to the appropriate level.

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated and WBCs move into the wound.

A 9-year-old child is brought to a health care facility after a fall on the playground. The nurse notes that surface layers of the skin have been scraped away in the fall. How would the nurse address this wound?

Cleanse the area with soap and water

The nurse would recognize which of these devices as an open drainage system?

Penrose drain

When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Perform hand hygiene.

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

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

After emptying a portable wound suction device, place the actions in the order in which the nurse would perform them?

Wipe the drainage spout with an antiseptic. Re-establish suction. Reinsert the drainage plug. Remove gloves. Perform hand hygiene. Return the client to a comfortable position

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

A nurse is assessing a client with a stage 4 pressure injury. What assessment of the injury would be expected?

full-thickness skin loss

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

gauze

When treating a client for a sprained ankle, the nurse wraps the client's ankle in a bandage. What is the purpose of wrapping the client's ankle in a bandage?

limits movement in the wound area

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

notify the physician and prepare for surgery

A nurse is caring for a client with a puncture wound in the proliferation phase of the wound repair process. Which description reflects this phase of the wound repair process?

period during which new cells fill and seal a wound

A nurse is assisting a physician who is using the sharp debridement technique at the bedside of a client at a health care facility. What is the purpose of sharp debridement?

removes necrotic tissue from healthy area of a wound

A group of nursing students is reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which as healing by primary intention?

surgical incision

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

transparent

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?

transparent film