Chapter 12 - Inflammation and Wound Healing, Tissue Integrity - NCLEX Questions

A client has an ischemic wound. This means that there has been: 1. A deficient blood supply to the tissue 2. Damage to the small blood vessels 3. Compression of the tissue 4. A combination of friction and pressure

1. A deficient blood supply to the tissue Explanation: insufficient blood supply to the tissue is ischemia. It is the cause of pressure ulcer formation.

When turning a client the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? 1. Clean area with mild soap, and dry. 2. Apply a dilute hydrogen peroxide and water mixture, and use a heat lamp on the area 3. Soak the area in normal saline solution 4. Wash the area with an astringent

1. Clean area with mild soap, and dry. Explanation: The skin should be cleansed and completely dried. B. Hydrogen peroxide can be irritating to the tissue and should not be used. A heat lamp is not necessary and would increase the client's risk of an accidental burn. C. The area should not be soaked, as this may lead to maceration of the skin. D. The area should not be cleansed with an astringent. An astringent may cause excessive drying of the tissue.

The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse's best response? 1. "As soon as he finishes his antibiotic prescription." 2. "As soon as his albumin level returns to normal." 3. "When fluid remobilization has started." 4. "When the burn wounds are closed."

4. "When the burn wounds are closed." Explanation: Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open.

A female client is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 1. 18% 2. 27% 3. 30% 4. 36%

4. 36% Explanation: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed

1, 3, & 4; Risk factors for pressure ulcers include a low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chance of skin breakdown.

In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client? 1. A urine output consistently above 100 ml/hour 2. A weight gain of 4 lb (2 kg) in 24 hours 3. Body temperature readings all within normal limits 4. An electrocardiogram (ECG) showing no arrhythmias

1. A urine output consistently above 100 ml/hour Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

When assessing a lesion diagnosed as malignant melanoma, the nurse in-charge most likely expects to note which of the following? 1. An irregular shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border

1. An irregular shaped lesion Explanation: A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? 1. Begin intravenous fluids 2. Check the pulses with a Doppler device 3. Obtain a complete blood count (CBC) 4. Obtain an electrocardiogram (ECG)

1. Begin intravenous fluids Explanation: Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Fluids can treat this problem. An ECG and CBC will be taken to ascertain if a cardiac or bleeding problem is causing these vital signs. However these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery but this is not an immediate nursing action.

A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

2140

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

A (Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing)

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Assess the ankle's range of motion (ROM). d. Assess whether the patient can bear weight on the affected ankle.

A (Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues)

A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound? a. Red wound b. Yellow wound c. Full-thickness wound d. Stage III pressure ulcer

A (The description is consistent with a red wound. A stage III pressure ulcer would expose subcutaneous fat. A yellow wound would have creamy colored exudate. A full-thickness wound involves subcutaneous tissue, which is not indicated in the wound description)

A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. b. Start antibiotic therapy. c. Redress the wound with wet-to-dry dressings. d. Continue to monitor the wound for purulent drainage.

A (The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well)

The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a "small amount of pain." How will the nurse categorize this injury? 1. Full-thickness 2. Partial-thickness superficial 3. Partial-thickness deep 4. Superficial

1. Full-thickness. Explanation: The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white in color with pain, and superficial burn color is pink to red, with pain.

When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? 1. Avoiding sharing equipment such as blood pressure cuffs between clients 2. Changing gloves between wound care on different parts of the client's body 3. Using the closed method of burn wound management 4. Using proper and consistent handwashing

2. Changing gloves between wound care on different parts of the client's body. Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client's body can prevent autocontamination.

The client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide? 1. "With reconstructive surgery, you can look the same." 2. "We can remove the scars with the use of a pressure dressing." 3. "You will not look exactly the same." 4. "You shouldn't start worrying about your appearance right now."

3. "You will not look exactly the same." Explanation: Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. Pressure dressings prevent further scarring. They cannot remove scars. The client and family should be taught the expected cosmetic outcomes.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound

A (With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing)

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours.

D (Mild to moderate temperature elevations (less than 103° F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation)

Why is a client with fever often predisposed to pressure ulcers? 1. Pain perception is diminished. 2. Medications given to relieve fever cause edema. 3. The client may be too weak to change position. 4. Increased metabolism causes increased oxygen needs that cannot be met.

4. Increased metabolism causes increased oxygen needs that cannot be met; Increased metabolism causes increased oxygen needs that cannot be met; therefore, a client with a fever is predisposed to pressure ulcers. Answers 1 and 2 are false statements. Answer 3 may be a cause of pressure ulcers and may occur in clients with fever, but it is not directly related.

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss of the dermis

4. Partial-thickness skin loss of the dermis Explanation: In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.

A patient's 4 ´ 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)

C (The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound)

A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.

D (Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be "just not feeling well.")

The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury? 1. Full-thickness 2. Partial-thickness superficial 3. Partial-thickness deep 4. Superficial

2. Partial-thickness superficial Explanation: The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and superficial burns, and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns are red to white in color.

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient takes insulin daily. b. The patient states that the ulcers are very painful. c. The patient has had the heel ulcers for the last 6 months. d. The patient has several old incisions that have formed keloids.

A (Chronic insulin use indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's pain will be implemented, but pain does not directly affect wound healing)

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

C (The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature)

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

D (Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing)

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member places contaminated dressings in a plastic grocery bag. d. The family member dries the wound using a hair dryer set on a low setting.

D (Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care)

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

D (Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate)

A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother? a. Change the patient's bedding frequently. b. Use a hydrocolloid dressing over the ulcer. c. Record the size and appearance of the ulcer weekly. d. Change the patient's position at least every 2 hours.

D (The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching, but the most important instruction is to change the patient's position at least every 2 hours)

The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment? 1. Lips 2. Sacrum 3. Earlobes 4. Back of the hands

1. Lips Explanation: In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge.

Which of the following clients would least likely be at risk of developing skin breakdown? 1. A client incontinent of urine feces 2. A client with chronic nutritional deficiencies 3. A client with decreased sensory perception 4. A client who is unable to move about and is confined to bed

3. A client with decreased sensory perception Explanation: Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk, as presented in the options, is the decreased sensory perception. Options 1, 2, and 4 identify physiological conditions, which are the risk priorities.

The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching? 1. "I'll limit my intake of protein." 2. "I'll make sure that the bandage is wrapped tightly." 3. "My foot should feel cold." 4. "I'll eat plenty of fruits and vegetables."

4. "I'll eat plenty of fruits and vegetables." Explanation: For effective tissue healing, adequate intake of protein, vitamin A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high protein diet with plenty of fruits and vegetables to provide these nutrients. The bandage should be secure but not too tight to impede circulation to the area (needed for tissue repair). If the client's foot feels cold, circulation is impaired, thus inhibiting wound healing.

During the acute phase of a burn, the nurse in-charge should assess which of the following? 1. Client's lifestyle 2. Alcohol use 3. Tobacco use 4. Circulatory status

4. Circulatory status Explanation: During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.

On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action? 1. Documenting the findings 2. Loosening any dressings on the chest 3. Raising the head of the bed 4. Preparing for intubation

4. Preparing for intubation Explanation: Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway. The swelling usually precludes intubation.

Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition? 1. Acute phase of the injury 2. Autodigestion of collagen 3. Granulation of burned tissue 4. Wound infection

4. Wound infection Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. These symptoms will not be seen in the acute phase of the injury. Autodigestion of collagen and granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge.

A male client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: 1. fluid resuscitation. 2. infection. 3. body image. 4. pain management.

4. pain management Explanation: With a superficial partial thickness burn such as a solar burn (sunburn), the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

A, D, B, C (The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last)

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

B (The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.)

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

C (A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues)

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles b. The newly admitted patient with a stage IV pressure ulcer on the coccyx c. The patient who has been receiving chemotherapy and has a temperature of 102° F d. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change

C (Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient)

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who has increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

D (LPN/LVN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN).)

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas

D (Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue)

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose 136 mg/dL b. Oral temperature 101° F (38.3° C) c. Patient complaint of increased incisional pain d. Separation of the proximal wound edges by 1 cm

D (Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly)

Using the Braden scale, which client is at highest risk for developing a pressure ulcer? 1. One with a score of 15 2. One with a score of 18 3. One with a score of 20 4. One with a score of 23

1. One with a score of 15 Explanation: clients with a score of less than 18 are at risk for developing a pressure ulcer. A maximum score is 23.

Which of the following is an example of a wound or injury that heals from secondary intention? 1. Pressure ulcer 2. Fracture 3. Sprained ankle 4. Surgical incision

1. Pressure ulcer Explanation: a pressure ulcer heals by secondary intention. The ends of the ulcer cannot be approximated. The wound must heal from the inside first.

Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict: 1. range of motion. 2. protein intake. 3. going outdoors. 4. fluid ingestion.

1. range of motion. Explanation: To prevent disruption of the artificial skin's adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn't be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should: 1. turn him frequently. 2. perform passive range-of-motion (ROM) exercises. 3. reduce the client's fluid intake. 4. encourage the client to use a footboard.

1. turn him frequently. Explanation: The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client? 1. Current range of motion in all extremities 2. Heart rate and rhythm 3. Respiratory rate and pulse oximetry reading 4. Orientation to time, place, and person

2. Heart rate and rhythm Explanation: The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. Range of motion and neurologic assessments are important. However the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.

Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is at increased risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.

2. Implement a turning schedule; the client is at increased risk for skin breakdown; A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.

Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? 1. Walking without shoes 2. Sitting in Fowler's position 3. Lying supine in bed 4. Using a heating pad

2. Sitting in Fowler's position; None of the other movements or situations creates the combination of friction and pressure with downward movement seen in bedridden clients positioned in Fowler's position.

The nurse notes a client's skin is reddened, with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2. Stage 2 Explanation: This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and appears as an abrasion, blister, or shallow crater. 1. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. The description is not consistent with a stage I pressure ulcer. 3. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through the muscle. The description is not consistent with a stage III pressure ulcer. 4. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. The description is not consistent with a stage IV pressure ulcer.

A male client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction would best prevent skin damage? 1. "Minimize sun exposure from 1 to 4 p.m. when the sun is strongest." 2. "Use a sunscreen with a sun protection factor of 6 or higher." 3. "Apply sunscreen even on overcast days." 4. "When at the beach, sit in the shade to prevent sunburn."

3. "Apply sunscreen even on overcast days." Explanation: Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn't guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun's rays onto the skin.

To reduce pressure points that may lead to pressure ulcers, the nurse should: 1. Position the client directly on the trochanter when side-lying 2. Use a donut device for the client when sitting up 3. Elevate the head of the bed as little as possible 4. Massage over the bony prominences

3. Elevate the head of the bed as little as possible Explanation: elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development form shearing forces.

A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? 1. How to maintain home smoke detectors 2. Joining a community reintegration program 3. Learning to perform dressing changes 4. Options available for scar removal

3. Learning to perform dressing changes Explanation: Critical for the goal of progression toward independence for the client is teaching clients and family members to perform care tasks such as dressing changes. All the other distractors are important in the rehabilitation stage. However, dressing changes have priority.

Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? 1. Turn and reposition the client at least once every 8 hours. 2. Vigorously massage lotion into bony prominences. 3. Post a turning schedule at the client's bedside. 4. Slide the client, rather than lifting, when turning.

3. Post a turning schedule at the client's bedside. Explanation: A turning schedule with a signing sheet will help ensure that the client gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing.

A client has been lying on her back for two hours. When the nurse turns her, the nurse notices the skin over her sacrum is very white. By the time the nurse finishes repositioning her, the spot has turned bright red. The nurse should: 1. Massage the spot with lotion 2. Apply a warm compress for 30 minutes 3. Return in 30-45 minutes to see if the redness has disappeared 4. Wash the area with soap and water and notify the physician

3. Return in 30-45 minutes to see if the redness has disappeared Explanation: the nurse would return to see if the skin has returned to its normal color. If not, it is a sign of damage to the tissue. 1: Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue and pressure ulcer formation. 2: A warm compress will increase circulation to the area. However the nurse would want to assess the area prior to application of the compress. 4: The nurse would make sure the area is clean but it is not the first nursing action. In some situations the physician would be notified.

When cleaning a wound, the nurse should: 1. Go over the wound twice and discard that swab 2. Move from the outer region of the wound toward the center 3. Start at the drainage site and move outward with circular motions 4. Cleanse the area around the drain and then clean the incision

3. Start at the drainage site and move outward with circular motions Explanation: To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in circular rotations outward from a point closest to the drain. A. The nurse never uses the same piece of gauze or swab to cleanse across an incision or wound twice. B. The wound should be cleansed in a direction from the least contaminated area, such as from the wound to the surrounding skin. The wound is cleaned from the center region to the outer region. D. The incision is cleansed first followed by the area around the drain