CH 32 PrepU

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

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

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? A. "I will put a layer of cloth between my skin and the ice pack." B. "I can let this stay on my ankle an hour at a time." C. "I should keep this on my ankle until it is numb." D. "I must wait 15 minutes between applications of cold therapy."

A. "I will put a layer of cloth between my skin and the ice pack."

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. a client sitting in a chair who slides down B. a client who lifts himself up on the elbows C. a client who must remain on the back for long periods of time D. a client who lies on wrinkled sheets

A. a client sitting in a chair who slides down

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

C. a surgical incision with sutured approximated edges

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? A. small amount of drainage that appears to be mostly fresh blood B. foul-smelling drainage that is grayish in color C. large amounts of drainage that is clear and watery and has no smell D. copious drainage that is blood-tinged

B. foul-smelling drainage that is grayish in color

When applying an external heating pad, which prescription from the health care provider would the nurse question? A. Maintain the temperature between 105°F to 109°F (40.5°C to 43°C) B. Assess site frequently during application of the heating pad C. Leave heating pad on for 45 minutes D. Use gauze to secure the heating pad to the site of application

C. Leave heating pad on for 45 minutes

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? A. Stage III B. Stage I C. Stage II D. Stage IV

C. Stage II

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? A. "How many meals a day do you eat?" B. "Do you use any lotions on your skin?" C. "Do you experience incontinence?" D. "Have you had any recent illnesses?"

C. "Do you experience incontinence?"

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? A. "That is old clotted blood underneath the wound" B. "This is normal tissue." C. "That is necrotic tissue, which must be removed to promote healing." D. "That is called undermining, a type of tissue erosion."

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

Which is not considered a skin appendage? A. Eccrine sweat glands B. Sebaceous gland C. Hair D. Connective tissue

D. Connective tissue

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? A. incision B. puncture C. avulsion D. contusion

D. contusion

An older adult client who is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply. - "Try to do everything by yourself at home to build your strength back." - "Eat nourishing foods after surgery to promote healing." - "Monitor your moods after surgery. Depression after surgery is not normal." - "It may take you longer to heal than someone younger." - "Wound healing can take longer if you have been exposed often to the sun."

- "Eat nourishing foods after surgery to promote healing." - "It may take you longer to heal than someone younger." - "Wound healing can take longer if you have been exposed often to the sun." - "Monitor your moods after surgery. Depression after surgery is not normal."

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 - Cyanosis - Decreased radial pulse - No finger numbness or tingling - Warm hand

- Fingers with quick capillary refill - No finger numbness or tingling - Warm hand

Which client(s) is considered at risk for skin alterations? Select all that apply. - a client undergoing cardiac monitoring - a client receiving radiation therapy - an adolescent with multiple body piercings - a client with diabetes - a client in a monogamous same-sex relationship

- an adolescent with multiple body piercings - a client receiving radiation therapy - a client with diabetes

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

A. 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? A. Apply saline solution-moistened gauze over the protruding area. B. Allow the wound and intestinal contents to remain open to air. C. Pack the wound with gauze pads and a dry sterile dressing. D. Inform the client that this is an expected occurrence and not to worry.

A. Apply saline solution-moistened gauze over the protruding area.

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 action should the nurse perform in obtaining a wound culture? A. Keep the swab and the inside of the culture tube sterile prior to collecting the culture. B. Cleanse the wound after obtaining the wound culture. C. Stroke the culture swab on surrounding skin first. D. Utilize the culture swab to obtain cultures from multiple sites.

A. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? A. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. B. Carefully pick the crusts off the sutures with the forceps before removing them. C. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. D. Do not attempt to remove the sutures because the wound needs more time to heal.

A. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

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. "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." B. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." C. "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." D. "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider."

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

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? A. Administer the prescribed analgesic. B. Assess the client's wound and vital signs. C. Notify the health care provider of the pain. D. Document the pain and vital signs.

B. Assess the client's wound and vital signs.

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. Infection of the wound B. Dehiscence of the wound C. Evisceration of the viscera D. Herniation of the wound

B. Dehiscence of the wound

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? A. Pasta salad B. Fish C. Banana D. Green beans

B. Fish

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? A. Apply an abdominal binder over the entire wound and drain to support the site. B. Secure the drain to the client's gown with a safety pin below the level of the wound. C. Tape the drain to the dressing material securely below the level of the wound. D. Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing.

B. Secure the drain to the client's gown with a safety pin below the level of the wound.

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? A. "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." B. "Be sure to take at least two showers daily to remove all microorganisms from the skin." C. "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." D. "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

D. "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? A. Clean the wound in a circular pattern, beginning on the perimeter of the wound. B. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. C. Use clean technique to clean the wound. D. Clean the wound from the top to the bottom and from the center to outside.

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

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 to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site? A. a dressing with a nonadherent coating B. a gauze dressing precut halfway to fit around the IV line C. a gauze dressing premedicated with antibiotics D. a transparent film

D. a transparent film