Chapter 28: Wound Care
A 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? *"Douching is recommended so that you are clean for the examination." *"Plan to begin douching routinely immediately after your procedure." *"Do not douche for 24-48 hours before the procedure." *"The Pap procedure includes application of a douche."
"Do not douche for 24-48 hours before the procedure."
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? *"I will put a layer of cloth between my skin and the ice pack." *"I should keep this on my ankle until it is numb." *"I must wait 15 minutes between applications of cold therapy." *"I can let this stay on my ankle an hour at a time."
"I will put a layer of cloth between my skin and the ice pack."
A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?
"I will restrict my diet to fats and carbohydrates."
A client birthed twins via cesarean and is learning to care for her incision. Which teaching will the nurse include? *"It is important to keep your sutured incision clean." *"Reinforced adhesive skin closures can be peeled off after 48 hours." *"You will have staples in place for several weeks." *"You only need a binder to hold your incision together."
"It is important to keep your sutured incision clean."
The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? * "You will receive medication through this device." *"The bulb-like system will stay in place permanently after your mastectomy." *"It provides a way to remove drainage and blood from the surgical wound." *"This drain minimizes the chance for bacteria to enter the surgical site."
"It provides a way to remove drainage and blood from the surgical wound."
The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What are the appropriate nursing responses? Select all that apply. *"We have to do this treatment to help your wound heal." *"If you do not have this debridement, you will get septicemia and possibly die." *"Medical maggots are sterilized before they are introduced to the wound." *"I understand your concern; let's talk further about your thoughts about this treatment." *"The choice regarding whether to have or decline this treatment is yours."
"Medical maggots are sterilized before they are introduced to the wound." "I understand your concern; let's talk further about your thoughts about this treatment." "The choice regarding whether to have or decline this treatment is yours."
The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? "You are seeing undermining, a type of tissue erosion." "This is normal tissue." "That is called slough, and it will usually fall off." "Necrotic tissue is devitalized tissue that must be removed to promote healing."
"Necrotic tissue is devitalized tissue that must be removed to promote healing."
The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. *"Your wound will be purposely left open for a time." *"Very little scar tissue will form." *"Your wound edges are right next to each other." *"This is a simple reparative process." *"The margins of your wound are widely separated."
"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other."
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? *"Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." *"If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." *"Your wound will heal slowly as granulation tissue forms and fills the wound." *"As soon as the infection clears, your surgeon will staple the wound closed."
"Your wound will heal slowly as granulation tissue forms and fills the wound."
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. A Penrose drain promotes passive drainage into a dressing. A Penrose drain is a closed drainage system that is connected to an electronic suction device.
A Penrose drain promotes passive drainage into a dressing.
What are the two major processes involved in the inflammatory phase of wound healing? *Bleeding is stimulated and epithelial cells are deposited. *Blood clotting is initiated and WBCs move into the wound. *Collagen is remodeled and an avascular scar forms. *Granulation tissue is formed and collagen is deposited.
Blood clotting is initiated and WBCs move into the wound.
The nurse is providing care to a postoperative client who has a Jackson-Pratt (JP) drain. The nurse notes that the JP drain is expanded and full of sanguineous fluid. Place in order the steps the nurse will now perform. Use all options. 1 Don clean gloves. 2 Note the amount of output, as well as its color. 3 Compress the chamber and replace the JP cap. 4 Empty the JP's contents into a graduated collection container. 5 Remove gloves and sanitize or wash hands
Don clean gloves. Empty the JP's contents into a graduated collection container. Compress the chamber and replace the JP cap. Note the amount of output, as well as its color. Remove gloves and sanitize or wash hands.
Dehiscence is the softening of tissue due to excessive moisture. *False *True
False
What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen? Knowledge Deficit regarding wound care related to laceration Impaired Skin Integrity related to open wound Pain related to wound sustained by knife Risk for Infection related to wound
Impaired Skin Integrity related to open wound
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? *Arteries and veins must be patent and functioning well. *The heart must be able to pump adequately. *The volume of circulating blood must be sufficient. *Local capillary pressure must be lower than external pressure.
Local capillary pressure must be lower than external pressure.
What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? *Risk for Infection *Risk for Imbalanced Nutrition *Self-Care Deficit *Anxiety
Risk for Infection
A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? *The wound is a 3 × 5-cm blood-filled blister. *The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. *The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. *The wound is 3 × 5 cm, with yellow tissue covering the entire wound.
The wound is 3 × 5 cm, with yellow tissue covering the entire wound.
The nurse should use extreme caution when applying heat therapy to which of the following clients? a client with a venous ulcer a client who is unconscious a client who is receiving corticosteroids a client with high pain sensitivity
a client who is unconscious
A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:
a laceration.
A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record?
a separation of skin and tissue in which the edges are torn and irregular
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 gauze dressing premedicated with antibiotics *a transparent film *a gauze dressing precut halfway to fit around the IV line *a dressing with a nonadherent coating
a transparent film
A client's risk for the development of a pressure injury is most likely due to which lab result? sodium 135 mEq/L glucose 110 mg/dL hemoglobin A1C 7% albumin 2.5 mg/dL
albumin 2.5 mg/dL
A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider? transparent hydrocolloid hydrogel alginate
alginate
A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider? *hydrogel *hydrocolloid *transparent *alginate
alginate
The nurse would recognize which client as being particularly susceptible to impaired wound healing? *A client who is NPO (nothing by mouth) following bowel surgery *an obese woman with a history of type 1 diabetes *a man with a sedentary lifestyle and a long history of cigarette smoking *a client whose breast reconstruction surgery required numerous incisions
an obese woman with a history of type 1 diabetes
The nurse is providing care for a client whose recent health deterioration has led to a nursing diagnosis of Risk for Impaired Tissue Integrity. What assessments should the nurse consequently perform? Select all that apply. *assessing the client's bowel and bladder function *monitoring the client's fluid intake *monitoring the client's nutritional status *assessing the client's level of mobility
assessing the client's bowel and bladder function monitoring the client's fluid intake monitoring the client's nutritional status assessing the client's level of mobility
The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?
assessing the wound for active bleeding
The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? *assessing the client's mental status *assessing for the use of antihypertensives *assessing the wound for active bleeding *assessing the client for claustrophobia
assessing the wound for active bleeding
A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care? cleanse the wound from the outer area toward the inner area cleanse with a new gauze for each stroke cleanse the wound in parallel strokes from the top to the bottom of the wound cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing
cleanse with a new gauze for each stroke
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? *incision *avulsion *puncture *contusion
contusion
Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and:
covering the wound area with sterile towels moistened with sterile 0.9% saline.
The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage?
figure-of-eight turn
Which type of wound drainage should alert the nurse to the possibility of infection? *large amounts of drainage that is clear and watery *drainage that appears to be mostly fresh blood *copious wound drainage that is blood-tinged *foul-smelling drainage that is grayish in color
foul-smelling drainage that is grayish in color
Which type of wound drainage should alert the nurse to the possibility of infection? foul-smelling drainage that is grayish in color large amounts of drainage that is clear and watery copious wound drainage that is blood-tinged drainage that appears to be mostly fresh blood
foul-smelling drainage that is grayish in color
A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected? *eschar formation *skin pallor *blister formation *full-thickness skin loss
full-thickness skin loss
The nurse has collected blood from a client for laboratory analysis. Which dressing will the nurse select to cover the site from which the blood was drawn? *tape with eyelets *transparent *hydrocolloid *gauze
gauze
The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood? *hydrocolloid *adhesive strips with eyelets *transparent *gauze
gauze
What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? alginate hydrocolloid dressing transparent film hydrogel
hydrocolloid 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? *incision *avulsion *laceration *abrasion
incision
A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client? enzymatic debridement biosurgical debridement autolytic debridement mechanical debridement
mechanical debridement
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? *administer pain medications intramuscularly *document the assessments and intervention *notify the physician and prepare for surgery *reinforce the dressing with additional layers
notify the physician and prepare for surgery
The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area? *supine with the head of the bed elevated 45 degrees *oblique *supine *Trendelenburg
oblique
A nurse is preparing to change the dressing on an elderly client's sacral wound that developed after a prolonged period of immobility prior to admission. Which action should the nurse perform while performing an aseptic change of this client's dressing? administering oral or subcutaneous analgesics during the dressing change irrigating the wound bed with chlorhexidine or hydrogen peroxide to remove debris from the wound bed performing hand washing before the dressing change and after removing the existing dressing donning sterile gloves before removing the existing dressing from the client's wound
performing hand washing before the dressing change and after removing the existing dressing
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? *improving the client's hydration *preventing the client from sliding in bed *lubricating the area with skin oil *pulling the client up from under the arms
preventing the client from sliding in bed
The nurse educator on a hospital's acute medical unit has created a document encouraging nurses to use cold applications when appropriate to clients' plans of care. What benefits of cold application should the educator cite?
prevention of swelling
Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? proliferation phase inflammatory phase maturation phase hemostasis
proliferation phase
Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? *maturation phase *hemostasis *inflammatory phase *proliferation phase
proliferation phase
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and has adhered to the wound bed. Which modification is most appropriate? discontinuing application of saline-moistened packing and applying a hydrocolloid dressing instead using less packing material reducing the interval between dressing changes ensuring that the packing material is completely saturated when placed in the wound
reducing the interval between dressing changes
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 purulent drainage from the wound bed in order to accurately assess it *removing dead or infected tissue to promote wound healing *removing excess drainage and wet tissue to prevent maceration of surrounding skin *stimulating the wound bed to promote the growth of granulation tissue
removing dead or infected tissue to promote wound healing
Which best describes the proliferative phase, the third phase of the wound healing process? reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization marked by vasodilation and phagocytosis as the body works to clean the wound the onset of vasoconstriction, platelet aggregation, and clot formation decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound
reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization
A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? desiccation primary intention tertiary intention secondary intention
secondary intention
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? primary intention maturation tertiary intention secondary intention
secondary intention
When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk?
shearing force
While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound? *stage III pressure injury *stage I pressure injury *stage II pressure injury *stage IV pressure injury
stage II pressure injury
A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? *stage II *stage IV *stage III *stage I
stage III
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury? *stage II *stage IV *stage I *stage III
stage III
A group of nursing students is reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which as healing by primary intention? *surgical incision *burn *pressure ulcer *deep laceration
surgical incision
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? *hydrocolloid *gauze *transparent *bandage
transparent
The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter? *hydrocolloid dressing *2 × 2 in (5 × 5 cm) gauze *hydrogel sheet *transparent film
transparent film
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? *elevate the head of the bed 90 degrees *place a foot board on the bed *provide incontinent care every 4 hours as needed *use pillows to maintain a side-lying position as needed
use pillows to maintain a side-lying position as needed
