Ch. 31 Course Point Quiz

A nurse assessing the skin of clients knows that the following are health states that may predispose clients to skin alterations.

-obesity -excessive perspiration -low BMI

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm x 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 this client's wound? a. Stage I b. Stage II c. Stage III d. Stage IV

Stage III

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

Definition of a wound

a disruption in normal skin and tissue integrity

Which is not considered a skin appendage? a. hair b. sebaceous gland c. eccrine sweat glands d. connective tissue

connective tissue

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

shearing force

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?

transparent film

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 is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound"

Which nursing interventions reflect the accurate use of heat or cold during wound care? a. The nurse applies moist cold to a client's eye for 40 minutes every 2 hours. b. The nurse makes more frequent checks of the skin of an older adult using a heating pad. c. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. d. The nurse instructs the client to lean or lie directly on the heating device. e. The nurse fills an ice bag with small pieces of ice to about two-thirds full. f. The nurse places a heating pad on a sprained wrist that is in the acute stage.

-The nurse makes more frequent checks of the skin of an older adult using a heating pad. -The nurse fills an ice bag with small pieces of ice to about two-thirds full. -The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains?

A Penrose drain promotes drainage passively into a dressing

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 -Wounds healed by primary intention are well approximated (skin edges tightly together).

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?

Biosurgical debridement

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage?

Serosanguineous

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

Stage II

True or false: a Penrose drain typically exits a client's skin through a stab wound created by the surgeon

True

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces?

a client sitting in a chair who slides down

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 client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The oncoming nurse receives in 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? a. a child's skin becomes less resistant to injury and infection as the child grows b. an individual's skin changes little over the life span c. an infant's skin and mucous membranes are easily injured and at risk for infection d. in children younger than 2 years, the skin is thicker and stronger than in adults

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? a. an obese woman with a history of type 1 diabetes b. A client who is n.p.o. (nothing by mouth) following bowel surgery c. a man with a sedentary lifestyle and a long history of cigarette smoking d. a client whose breast reconstruction surgery required numerous incisions

an obese woman with a history of type 1 diabetes -Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process.

The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? a. Assess the client for claustrophobia. b. Assess the wound for active bleeding. c. Assess the client's mental status. d. Assess for the use of antihypertensives.

assess the wound for active bleeding

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? a. clean the wound from bottom to top, and outside to center b. once wound is cleaned, dry the area with an absorbent cloth c. clean the wound from the top to the bottom, and center to outside d. use clean technique to clean the wound

clean the wound from the top to the bottom, and center to outside

The nurse is performing pressure ulcer assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure ulcer? a. a newborn b. a client with cardiovascular disease c. a critical care client d. an older client with arthritis

critical care client (think Braden Scale)

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

dehiscence is when a wound has partial or total separation of the wound layers

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing? a. Fish b. Green beans c. Banana d. Pasta salad

fish -ensure a diet high in protein, vitamin A, and vitamin C

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? a. The volume of circulating blood must be sufficient. b. Local capillary pressure must be lower than external pressure. c. Arteries and veins must be patent and functioning well. d. The heart must be able to pump adequately.

local capillary pressure must be lower than external pressure

In the older adult client, wrinkling is related to:

loss of elasticity

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention

A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain? a. Provides a sinus tract for drainage b. Provides drainage for bile c. Decreases dead space by decreasing drainage d. Diverts drainage to the peritoneal cavity

provides drainage for bile

A client who was injured when he stepped on a rusted nail visits the health care facility. How should the nurse describe this wound?

puncture

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

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer? a. pull client up under arms b. lubricate the area with skin oil c. support the client from sliding in bed d. improve the client's hydration

support the client from sliding in bed

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 20-30 minutes, assessing it regularly

A nurse is evaluating a client who was admitted with second degree burns. Which describes a second-degree burn?

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