Ch. 31: Skin Integrity and Wound Care

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? a) Depth b) Tunneling c) Size d) Direction

Depth Explanation: When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler.

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? a) "Dehiscence is a total separation of the wound with protrusion of the viscera through it." b) "Dehiscence is the softening of tissue due to excessive moisture." c) "Dehiscence is when a wound has partial or total separation of the wound layers." d) "Dehiscence is not anything that you need to worry about."

"Dehiscence is when a wound has partial or total separation of the wound layers." Explanation: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound

The nurse and client are looking at a client's heel pressure ulcer. The client states, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? a) "Necrotic tissue is devitalized tissue that must be removed to promote healing." b) "This is normal tissue." c) "That is called slough, and it will usually fall off." d) "You are seeing undermining, a type of tissue erosion."

"Necrotic tissue is devitalized tissue that must be removed to promote healing." Explanation: The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include? a) "The surgeon will leave your wound intentionally open for a period of time." b) "The margins of your wound are not in direct contact." c) "Very little scar tissue will form." d) "This is a complex reparative process."

"Very little scar tissue will form." Explanation: Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process where margins of the wound are not in direct contact. Third-intention healing takes place when wound edges are intentionally left widely separated and are later brought together for closure.

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention? a) Apply sterile dressings with normal saline over the protruding organs and tissue. b) Contact the surgeon. c) Monitor for pallor and mottle appearance of the wound. d) Assess for impaired blood flow to the area of evisceration.

Apply sterile dressings with normal saline over the protruding organs and tissue. Explanation: The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue, and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

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

Clean the wound from the top to the bottom, and center to outside. Explanation: Using sterile technique, clean the wound from the top to the bottom, and from the center to the outside. Dry the area with a gauze sponge in the same manner and apply ointment and dressing.

The nurse caring for client that had abdominal surgery 12 hours ago notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? a) Notify the wound care nurse. b) Document the findings. c) Change the dressing. d) Contact the physician.

Document the findings. Explanation: The nurse should document the findings and continue to monitor the dressing. As it is a small amount of drainage, there is no need to contact the physician or the wound care nurse. The nurse should not change the dressing, as the dressing is still the surgical dressing and most often the surgeon will change the first surgical dressing within 24 to 48 hours.

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 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.

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

Local capillary pressure must be lower than external pressure. Explanation: Local capillary pressure must be higher than external pressure for adequate skin perfusion.

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? a) Stage IV b) Stage III c) Stage II d) Stage I

Stage II Explanation: A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater

A nurse is assessing a pressure ulcer 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? a) Stage II b) Stage III c) Stage I d) Stage IV

Stage III Explanation: Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscles

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? a) Gauze b) Transparent c) Hydrocolloid d) Bandage

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. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. a) True b) False

True Explanation: A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract.

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 ulcer? a) Elevate the head of the bed 90 degrees. b) Use pillows to maintain a side-lying position as needed. c) Place a foot board on the bed. d) Provide incontinent care every 4 hours as needed.

Use pillows to maintain a side-lying position as needed. Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation to the skin. A foot board prevents footdrop in clients but does not decrease the risk for pressure ulcers.

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) a gauze dressing premedicated with antibiotics b) a dressing with a nonadherent coating c) a transparent film d) a gauze dressing precut halfway to fit around the IV line

a transparent film Explanation: Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings do not allow the nurse to visualize the site without partially or completely removing the dressing

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? a) avulsion b) abrasion c) incision d) laceration

incision Explanation: An incision involves a clean separation of skin and tissue with smooth, even edges. Therefore, the nurse documents the finding as an incision. An avulsion has stripped away of large areas of skin and underlying tissues. An abrasion involves stripped surface layers of skin. A laceration involves separation of skin and tissue with torn, irregular edges. Therefore, the nurse does not document the finding as an avulsion, abrasion, or laceration.

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? a) removing dead or infected tissue to promote wound healing b) removing purulent drainage from the wound bed in order to accurately assess it c) stimulating the wound bed to promote the growth of granulation tissue d) removing excess drainage and wet tissue to prevent maceration of surrounding skin

removing dead or infected tissue to promote wound healing Explanation: Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question? a) "Do you use any lotions on your skin?" b) "Do you experience incontinence?" c) "How many meals a day do you eat?" d) "Have you had any recent illnesses?"

"Do you experience incontinence?" Explanation: The client's health history is an essential component for assessing the client's integumentary status and identification of risk factors for problems with the skin.

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer? a) 65-year-old incontinent client with a hip fracture on bed rest b) 70-year-old client with Alzheimer's who wanders the nursing unit and refuses to sit and eat meals c) 35-year-old client who was admitted after a motor vehicle accident and has bilateral casts d) 45-year-old client who has cancer, is receiving chemotherapy, and being admitted with leukopenia

65-year-old incontinent client with a hip fracture on bed rest Explanation: The 65-year-old client who is incontinent with a hip fracture would be at highest risk for developing a pressure ulcer. This client has several risk factors: age, incontinence, and decreased mobility related to the hip fracture.

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the client's chance of skin breakdown? a) Keep the client in a semi-Fowler's or high-Fowler's position. b) Massage or stimulate the client's skin surfaces daily. c) Reposition the client on a regular basis. d) Ensure the client is adequately hydrated.

Reposition the client on a regular basis. Explanation: For clients who are immobilized, it is imperative to regularly turn and reposition the client in order to prevent ischemia and consequent skin breakdown.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a) a wound healing naturally that becomes infected. b) a large wound with considerable tissue loss allowed to heal naturally c) a wound left open for several days to allow edema to subside d) a surgical incision with sutured approximated edges

a surgical incision with sutured approximated edges Explanation: Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention

Which type of wound drainage should alert the nurse to the possibility of infection? a) foul-smelling drainage that is grayish in color b) copious wound drainage that is blood-tinged c) large amounts of drainage that is clear and watery d) drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection.

The nurse has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn? a) gauze b) Tegasorb c) Montgomery strap d) OpSit

gauze Explanation: Gauze dressings absorb blood or drainage. Montgomery straps are strips of tape with eyelets which are used to secure a gauze dressing that needs frequent changing; they are not necessary for this type of wound. Transparent dressings like OpSite are used to protect intravenous insertion sites. Hydrocolloid dressings like Tegasorb are used to used keep a wound moist

The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment? a) "Douching is recommended so that you are clean for the examination." b) "The Pap procedure includes application of a douche." c) "Do not douche 24-48 hours before the procedure." d) "Plan to begin douching routinely immediately after your procedure."

"Do not douche 24-48 hours before the procedure." Explanation: Clients should be informed to refrain from douching 24-48 hours prior to a Pap test, as this can wash away diagnostic cells. The healthcare provider is unlikely to recommend routine douching; this procedure is usually used to assist with treatment of an infection. The Pap procedure involves obtaining cell samples; it does not include application of a douche.

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? a) Exert equal, but not excessive, tension with each turn of the bandage. b) Wrap distally to proximally. c) Keep bandage free from gaps between each turn. d) Elevate and support the stump.

Elevate and support the stump. Explanation: The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

A student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as "unstageable." Which wound description should the student nurse expect to assess? a) The wound is 3 cm × 5 cm with yellow tissue covering the entire wound. b) The wound is 3 cm × 5 cm with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. c) The wound is a 3 cm × 5 cm blood-filled blister. d) The wound is 3 cm × 5 cm with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing.

The wound is 3 cm × 5 cm with yellow tissue covering the entire wound. Explanation: The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound is unable to be determined because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendons, muscles, or bones exposed. A suspected deep tissue injury presents as a maroon or purple lesion or a blood-filled blister.

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 client whose breast reconstruction surgery required numerous incisions d) a man with a sedentary lifestyle and a long history of cigarette smoking

an obese woman with a history of type 1 diabetes Explanation: 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. This is a greater risk factor for impaired healing than is smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition

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: a) primary intention. b) secondary intention. c) tertiary intention. d) dehiscence.

primary intention. Explanation: Wounds healing by primary intention form a clean, straight line with little loss of tissue. Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue. Wounds healing by delayed primary intention or tertiary intention are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed. Dehiscence is wound separation, not wound 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? a) "It allows for removal of blood and drainage from the surgical wound." b) "The drain is part of the knee replacement; it stays attached permanently." c) "I place antibiotic ointment in the bulb and squeeze it into the wound." d) "This drain decreases the pain associated with the knee replacement."

"It allows for removal of blood and drainage from the surgical wound." Explanation: The bulb-like drain allows for removal of blood and drainage from the surgical wound. It does not decrease the pain level, nor does it stay attached permanently. The nurse empties the drain, but does not place medication inside it.

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching? a) "I will not remove the staples myself." b) "I may have staples in place for a number of days." c) "After delivery, I will have sutures in place." d) "Steri-Strips will hold my wound together until it heals."

"Steri-Strips will hold my wound together until it heals." Explanation: After a Cesarean section, a client will be sutured and have staples put in place for a number of days. The healthcare provider or nurse will remove staples. Steri-Strips are not strong enough to hold this type of wound together.

The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate? a) "You may be correct. I will check with your primary health care provider." b) "Allowing a scab to form would prevent us from observing the wound for signs of infection." c) "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." d) "Wounds heal better when a moist wound bed is maintained."

"Wounds heal better when a moist wound bed is maintained." Explanation: A moist wound surface enhances the cellular migration necessary for tissue repair and healing.

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? a) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." b) "As soon as the infection clears, your surgeon will staple the wound closed." c) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." d) "Your wound will heal slowly as granulation tissue forms and fills the wound."

"Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: There is no indication of infection. Large wounds with extensive tissue loss may not be able to be closed by primary intention

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? a) Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles. b) Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. c) Use an aquathermia pad during the treatment to create heat and circulate the water. d) Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Explanation: Warm soaks and dressing changes can be painful for clients with abscesses. Often, nurses will premeditate with pain medications, often narcotics, 20-30 to make the treatments more comfortable for clients. Increasing client comfort can increase effectiveness by allowing the nurse time to adequately perform the treatment, assess the wound, and apply the new dressing. Aquathermia pads are used to promote wound healing, but they are not used simultaneously with water therapies. Dangling the legs and ambulating will not increase comfort.

The nurse is caring for a client who has a heavy exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? a) An alginate dressing such as AlgiCell b) An antimicrobial dressing such as SilvaSorb c) Transparent film such as Tegaderm d) A hydrogel dressing such as Aquasorb

An alginate dressing such as AlgiCell Explanation: Antimicrobial dressings are appropriate for chronic wounds at risk for infection.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a) An individual's skin changes little over the life span. b) In children younger than 2 years, the skin is thicker and stronger than in adults. c) A child's skin becomes less resistant to injury and infection as the child grows. d) An infant's skin and mucous membranes are easily injured and at risk for infection.

An infant's skin and mucous membranes are easily injured and at risk for infection. Explanation: An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

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 for the use of antihypertensives. b) Assess the wound for active bleeding. c) Assess the client's mental status. d) Assess the client for claustrophobia.

Assess the wound for active bleeding. Explanation: Negative-pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed. NPWT is not considered for the use in the presence of active bleeding. The nurse needs to assess for the use of anticoagulants, not antihypertensives, because these can cause bleeding. Mental status and the presence of claustrophobia are not significant when initiating negative-pressure wound therapy.

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? a) Enzymatic debridement b) Autolytic debridement c) Biosurgical debridement d) Mechanical debridement

Biosurgical debridement Explanation: Biosurgical debridement uses fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement.

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 ulcer development? a) Morse scale b) Glascow scale c) FLACC scale d) Braden scale

Braden scale Explanation: The Braden scale is an assessment tool used to assess the client's risk for pressure ulcer development. The Glascow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls

Which is not considered a skin appendage? a) Eccrine sweat glands b) Sebaceous gland c) Connective tissue d) Hair

Connective tissue Explanation: Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.

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? a) Herniation of the wound b) Infection of the wound c) Evisceration of the viscera d) Dehiscence of the wound

Dehiscence of the wound Explanation: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician.

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication? a) Dehiscence b) Evisceration c) Fistula d) Hemorrhage

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.

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 of the following actions should the nurse perform in obtaining a wound culture? a) Utilize the culture swab to obtain cultures from multiple sites. b) Keep the swab and inside of the culture tube sterile. c) Stroke the culture swab on surrounding skin first. d) Cleanse the wound after obtaining the wound culture.

Keep the swab and inside of the culture tube sterile. Explanation: The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surround the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

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

Support the client from sliding in bed. Explanation: Shearing force occurs when tissue layers move on each other, causing vessels to stretch as they pass through the subcutaneous tissue.

A nurse is caring for a client who has an avulsion of her left thumb. Which of the following descriptions should the nurse understand as being the definition of avulsion? a) Tearing of a structure from its normal position b) Cutting with a sharp instrument with wound edges in close approximation with correct alignment c) Tearing of the skin and tissue with some type of instrument: tissue not aligned d) Puncture of the skin

Tearing of a structure from its normal position Explanation: An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edged in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition? a) The edges of the wound are lightly pulled together. b) There is an unintentional separation of the wound. c) There is an accumulation of fluid in the interstitial tissue. d) There is redness or inflammation of an area as a result of dilation.

There is an unintentional separation of the wound. Explanation: With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together. Edema is an accumulation of fluid in the interstitial tissue. Redness or inflammation of an area as a result of dilation is erythema.

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) a client who lifts himself up on his elbows b) a client who lies on wrinkled sheets c) a client sitting in a chair who slides down d) a client who must remain on his back for long periods of time

a client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin.

What is the most accurate definition of a wound? a) a disruption in normal skin and tissue integrity b) any trauma resulting in serious damage and pain c) a change in the function of internal organs d) any injury that results in changes in nervous tissue

a disruption in normal skin and tissue integrity Explanation: A wound is a break or disruption in the normal integrity of the skin and tissues. The disruption may range from a small cut on the finger to a third-degree burn covering almost all of the body.

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) a sterile, flexible applicator moistened with saline b) an otic curette c) a small plastic ruler d) a sterile tongue blade lubricated with water soluble gel

a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use. The other implements are too large, inflexible, or not sterile.

In the older adult client, wrinkling is related to: a) loss of protein. b) loss of circulation. c) loss of elasticity. d) loss of fat.

loss of elasticity. Explanation: Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue.

The nurse observes the client for signs of stage I pressure ulcer development, which is most likely to include which finding? a) exposed bone with eschar b) visible subcutaneous fat c) a shallow, open ulcer d) nonblanchable redness

nonblanchable redness Explanation: A stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence. A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage III ulcer presents with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Stage IV ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

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? a) shearing force b) friction c) necrosis of tissue d) ischemia

shearing force Explanation: A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

A student nurse studying anatomy and physiology learns that the largest organ of the body is the: a) heart. b) intestines. c) lungs. d) skin.

skin. Explanation: The skin, or integument, is the largest organ of the body and has multiple functions. The integumentary system is made up of the skin, the subcutaneous layer directly under the skin, and the appendages of the skin, including glands in the skin, hair, and nails. The integumentary system also includes the blood vessels, nerves, and sensory organs of the skin. The skin is essential for maintaining life.

A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn? a) superficial, may be pinkish or red with no blistering b) also called a superficial partial-thickness burn, can appear dry and leathery c) may vary from brown or black to cherry red or pearly white; bullae may be present d) usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown

usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown Explanation: Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. a) Clean the wound from top to bottom. b) Avoid touching the wound bed, whether with gloves or forceps. c) Clean from the outside of the wound to the center. d) Use a new gauze for each wipe of the wound. e) Use a sterile applicator to apply any ointment that is ordered.

• Clean the wound from top to bottom. • Use a sterile applicator to apply any ointment that is ordered. • Use a new gauze for each wipe of the wound. • Avoid touching the wound bed, whether with gloves or forceps. Explanation: Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps