Chapter 30 Skin Integrity and Wound Healing
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? - "This is a complex reparative process." - "The surgeon will leave your wound open intentionally for a period of time." - "Very little scar tissue will form." - "The margins of your wound are not in direct contact."
"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 in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.
When measuring the size, depth, and wound tunneling of a client's stage IV pressure injury, what action should the nurse perform first? - Assess the condition of the visible wound bed. - Insert a swab into the wound at 90 degrees. - Measure the width of the wound with a disposable ruler. - Perform hand hygiene.
Perform hand hygiene. Explanation: Hand hygiene should precede any wound assessment or wound treatment. Performing hand hygiene prior to the wound assessment reduces the risk for infection. Inserting a swab into the wound at 90 degrees, measuring the width of the wound with a disposable ruler, and assessing the condition of the visible wound bed are all appropriate wound assessments.
A physician uses sutures during the surgery on a client at a health care facility. What are sutures? - a bridge that holds two wound margins together - tubes that provide a pathway for drainage - a strip or roll of cloth wrapped around a body part - knotted ties that hold an incision together
knotted ties that hold an incision together Explanation: Sutures are knotted ties that hold an incision together. Sutures generally are constructed from silk or synthetic materials such as nylon. Staples are wide metal clips that form a bridge to hold two wound margins together. A bandage is a strip or roll of cloth wrapped around a body part. Open drains are tubes that provide pathways for drainage toward the dressing.
Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? - taking medications as prescribed - adequate sleep and rest - proper intake of food and fluids - thorough hand hygiene
thorough hand hygiene Explanation: The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections. Proper intake of fluids and fiber as well as adequate sleep and rest are general guidelines to promote health. Taking medications especially antibiotics are important if an infection occurs.
Which clients would be considered at risk for skin alterations? Select all that apply. - a client with diabetes - a teenager with multiple body piercings - a client undergoing cardiac monitoring - a homosexual in a monogamous relationship - a client receiving radiation therapy
- a teenager with multiple body piercings - a client receiving radiation therapy - a client with diabetes Explanation: Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a homosexual relationship with multiple partners would also place a client at risk for HIV and skin alterations. Cardiac monitoring and respiratory disorders are not risk factors.
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 puncture. - an abrasion. - a laceration. - a contusion.
a laceration. Explanation: A laceration is a wound with ragged edges with torn tissue. An abrasion is a wound involving friction of the skin. A contusion is a closed wound with bleeding in underlying tissues. A puncture is a wound involving penetration of the skin and underlying 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? - incision - contusion - puncture - avulsion
contusion Explanation: A contusion is an injury to soft tissue, so this is what the nurse expects to see on the basis of the teacher's description of the incident. A puncture involves an opening in the skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripping of the surface layers of skin. In an avulsion injury, large areas of skin and underlying tissues have been stripped away.
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: - holding the wound together until the health care provider arrives. - covering the wound area with sterile towels moistened with sterile 0.9% saline. - closing the wound area with reinforced adhesive skin closures. - pouring sterile hydrogen peroxide into the abdominal cavity and packing it with gauze.
covering the wound area with sterile towels moistened with sterile 0.9% saline. Explanation: If dehiscence occurs, the nurse should cover the wound area with sterile towels moistened with sterile 0.9% saline. The nurse should also place the client in the low Fowler position and cover the exposed abdominal contents with sterile saline, not hydrogen peroxide. The nurse notifies the health care provider immediately, because this is a medical emergency. The nurse should not leave the client alone but does not need to hold the wound together until the health care provider arrives.
A nurse applies an aquathermia pad on the back of a client with arthritis. What is the expected action that will occur with this application of heat? - dilated peripheral blood vessels - increased venous congestion - decreased blood flow to the area - decreased inflammatory response
dilated peripheral blood vessels Explanation: Heat dilates peripheral blood vessels, helping to dissipate heat from the body and to increase blood flow to the area. This increases the supply of oxygen and nutrients to the area and reduces venous congestion. Heat applications accelerate the inflammatory response, promoting healing.
Which type of wound drainage should alert the nurse to the possibility of infection? - copious wound drainage that is blood-tinged - drainage that appears to be mostly fresh blood -foul-smelling drainage that is grayish in color - large amounts of drainage that is clear and watery
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.
A nurse is assisting a physician who is using the sharp debridement technique at the bedside of a client at a health care facility. What is the purpose of sharp debridement? - physically removes exudate from a deep wound - removes necrotic tissue from healthy area of a wound - allows the body's enzymes to soften and liquefy tissue - breaks down and liquefies wound debris
removes necrotic tissue from healthy area of a wound Explanation: In the sharp debridement technique, necrotic tissue is removed from a healthy area of a wound with the use of sterile scissors, forceps, or other instruments. This method is preferred if the wound is infected, because it helps the wound heal quickly and well. The procedure is done at the bedside, or in the operating room if the wound is extensive. Enzymatic debridement involves the use of topically applied chemical substances that break down and liquefy wound debris. Autolytic debridement, or self-dissolution, is a painless natural physiologic process that allows the body's enzymes to soften, liquefy, and release devitalized tissue. Mechanical debridement involves physical removal of debris from a deep wound.
A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? - sanguineous - serosanguineous - purulent - serous
serosanguineous. Explanation: The nurse should document the drainage as serosanguineous, which is pale pink-yellow, thin, and contains plasma and red cells. Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.
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 - necrosis of tissue - friction - 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 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? - deep laceration - burn - pressure ulcer - surgical incision
surgical incision Explanation: Clean surgical incisions heal by primary intention. Pressure ulcers, burns, and deep lacerations typically heal by secondary intention.
The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? - hydrocolloid - adhesive strips with eyelets - gauze - transparent
transparent Explanation: Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist.
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? - place a foot board on the bed - use pillows to maintain a side-lying position as needed - elevate the head of the bed 90 degrees - 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 of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.
Which statement accurately describes a developmental consideration when assessing skin integrity of clients? - In children younger than 2 years, the skin is thicker and stronger than it is in adults. - A child's skin becomes increasingly at risk for injury and infection. - In the older adult, circulation and collagen formation are increased. - An infant's skin and mucous membranes are injured easily and are subject to infection.
An infant's skin and mucous membranes are injured easily and are subject to infection. Explanation: In children younger than 2 years, the skin is thinner and weaker than it is in adults. An infant's skin and mucous membranes are injured easily and are subject to infection. Careful handling of infants is required to prevent injury to, and infection of, the skin and mucous membranes. A child's skin becomes increasingly resistant to injury and infection. The structure of the skin changes as a person ages. The maturation of epidermal cells is prolonged, leading to thin, easily-damaged skin. Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.
What are the two major processes involved in the inflammatory phase of wound healing? - 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. - Bleeding is stimulated and epithelial cells are deposited.
Blood clotting is initiated and WBCs move into the wound. Explanation: The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation, when WBCs move into the wound. Granulation and collagen deposition are initiated not in the inflammatory process but rather in the healing phase. Bleeding occurs in the injury phase.
Which is not considered a skin appendage? - Connective tissue - Hair - Eccrine sweat glands - Sebaceous gland
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 nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? - Dermis - Muscle layer - Subcutaneous tissue - Epidermis
Subcutaneous tissue Explanation: The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? - May vary from brown or black to cherry red or pearly white; bullae may be present - Superficial, which may be pinkish or red with no blistering - Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown - A superficial partial-thickness burn, which can appear dry and leathery
Usually moist with blisters, which 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.
The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? - figure-of-eight turn - spica turn - spiral-reverse turn - circular turn
figure-of-eight turn Explanation: A figure-of-eight turn is used for joints like the elbows and knees. The other answers are incorrect.
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? - "That is called undermining, a type of tissue erosion." - "That is old clotted blood underneath the wound" - "This is normal tissue." - "That is necrotic tissue, which must be removed to promote healing."
"That is necrotic tissue, which must be removed to promote healing." Explanation: Wounds that are brown or black are necrotic and not considered normal. 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 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 can let this stay on my ankle an hour at a time." - "I must wait 15 minutes between applications of cold therapy." - "I should keep this on my ankle until it is numb."
"I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.
A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands? - "I will alternate between positive and negative pressure every 2 hours." - "I will squeeze the chamber and apply the cap to maintain negative pressure." - "I will check and empty the drain every 6 hours." - "I will apply a dressing at the end of the drain to catch any drainage.
"I will squeeze the chamber and apply the cap to maintain negative pressure." Explanation: The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain has gauze at the end of the drain to catch drainage.
The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? - "I will not remove the staples myself." - "I may have staples in place for a number of days." - "After delivery, I will have sutures in place." - "Reinforced adhesive skin closures will hold my wound together until it heals."
"Reinforced adhesive skin closures will hold my wound together until it heals." Explanation: After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples. Reinforced adhesive skin closures are not strong enough to hold this type of wound together.
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. - "The margins of your wound are widely separated." - "Very little scar tissue will form." - "Your wound will be purposely left open for a time." - "Your wound edges are right next to each other." - "This is a simple reparative process."
"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other." Explanation: Very little scar tissue is expected to form during first-intention healing in a wound whose wound edges are close to each other. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.
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? - "As soon as the infection clears, your surgeon will staple the wound closed." - "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." - "Your wound will heal slowly as granulation tissue forms and fills the wound." - "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." Explanation: This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.
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 injury development? - FLACC scale - Braden scale - Glascow scale - Morse scale
Braden scale Explanation: The Braden scale is an assessment tool used to assess the client's risk for pressure injury 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.
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? - Clean the wound from the top to the bottom and from the center to outside. - Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. - Use clean technique to clean the wound. - Clean the wound in a circular pattern, beginning on the perimeter of the wound.
Clean the wound from the top to the bottom and from the 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, not an absorbent cloth.
Which action should the nurse perform when applying negative pressure wound therapy? - Test the seal of the completed dressing by briefly attaching it to wall suction. - Irrigate the wound thoroughly using normal saline and clean technique. - Cut foam to the shape of the wound and place it in the wound. - Increase the negative pressure setting until drainage is brisk.
Cut foam to the shape of the wound and place it in the wound. Explanation: When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.
The nurse is preparing to irrigate a client's wound. Arrange the following steps in the correct order.
Don a mask, gown, and eye protection. Carefully remove the soiled dressing. Don sterile gloves. Fill the irrigation syringe with warmed irrigation solution. Gently direct a stream of solution into the wound. Dry the surrounding skin with gauze dressings. Explanation: The order of steps: 1. Don a mask, gown, and eye protection. 2. Carefully remove the soiled dressing. 3. Don sterile gloves. 4. Fill the irrigation syringe with warmed irrigation solution. 5. Gently direct a stream of solution into the wound. 6. Dry the surrounding skin with gauze dressings.
A physician orders a wound irrigation to apply local antiseptics to a client's wound. What is a guideline for performing this procedure? - If the wound is closed, clean technique may be used instead of sterile technique. - If bleeding is noted that was not previously there, the nurse should continue irrigation and then notify the physician. - When the solution from the wound turns light pink, the irrigation should be stopped. - Sterile water is often the solution of choice when irrigating wounds.
If the wound is closed, clean technique may be used instead of sterile technique. Explanation: Clean technique can be used on a closed wound. Saline solution is the common solution of choice when performing an irrigation. When the solution from the wound turns clear, the irrigation should be discontinued. If bleeding is noted that was not previously there, the nurse should stop the irrigation and notify the physician.
As a part of the senior citizen health program, the community health nurse arranges a free skin screening for the older adults. Which of the following would the nurse find when assessing the skin of older adult clients? - Acne vulgaris - Liver spots - Lanugo - Milia
Liver spots Explanation: The nurse would find liver spots in the older adult client. Also called senile lentigines, liver spots are pigmentation changes that occur on sun-exposed areas. Milia, lanugo, and acne vulgaris are not found in older adults. Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose that appear during the first few weeks of life. Lanugo is fine hair that covers the body of the newborn. Acne vulgaris is a common skin disorder found in adolescents.
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? - Self-Care Deficit - Anxiety - Risk for Imbalanced Nutrition - Risk for Infection
Risk for Infection Explanation: Clients who are taking corticosteroid medications are at high risk for delayed healing and wound complications such as infections. Corticosteroids decrease the inflammatory process, which may in turn delay healing. Self-Care Deficit may occur with a client who has challenges with physical ability. Imbalanced Nutrition would occur with a client who cannot take in adequate nutrition. Anxiety can occur with clients who have psychological issues.
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? - Stage I - Stage III - Stage II - Stage IV
Stage II Explanation: A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries 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.
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? - Stage II - Stage I - Stage III - Stage IV
Stage II Explanation: A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries 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.
A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply. - a wound with increased swelling and drainage that may occur during the first 5 days of wound healing - a wound that does not feel hot and tender upon palpation incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes - a wound that takes approximately 2 weeks for the edges to appear approximated and heal together - a wound that forms exudate due to the inflammatory response - The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges.
The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot and tender upon palpation a wound that forms exudate due to the inflammatory response Explanation: The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. This would be a correct way to document a normally healing wound. A wound that does not feel hot upon palpation would be another example of correctly documenting a wound that has no complications. A wound that is warm to touch is not an abnormal finding. A wound that forms exudate due to the inflammatory response would be correct documentation of a normal finding.
The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? - The nurse packs the wound cavity tightly with dressing material. - The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. - The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. - The nurse uses wet-to-dry dressings continuously.
The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. Explanation: A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.
The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? - The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. - The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. - The nurse packs the wound cavity tightly with dressing material. - The nurse uses wet-to-dry dressings continuously.
The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. Explanation: A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? - The nurse swabs the wound from the bottom to the top. - The nurse uses friction when cleaning the wound to loosen dead cells. - The nurse swabs the wound with povidone-iodine to fight infection in the wound. - The nurse works outward from the wound in lines parallel to it.
The nurse works outward from the wound in lines parallel to it. Explanation: A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? - The nurse swabs the wound with povidone-iodine to fight infection in the wound. - The nurse swabs the wound from the bottom to the top. - The nurse works outward from the wound in lines parallel to it. - The nurse uses friction when cleaning the wound to loosen dead cells.
The nurse works outward from the wound in lines parallel to it. Explanation: A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.
When the nurse is caring for a client with an open wound, which characteristic should be observed if the wound heals by primary intention? - The wound edges have to be brought together with closure material. - The wound edges are directly next to each other. - Granulation tissue needs additional time to extend across the wound. - Drainage devices have to be used to promote quick healing.
The wound edges are directly next to each other. Explanation: If the wound is to heal by primary intention, the wound edges are directly next to each other. Because the space between the wound edges is so narrow, only a small amount of scar tissue forms. If the wound edges are widely separated, leading to a more time-consuming and complex reparative process, then it is described as healing by secondary intention. With tertiary intention healing, the wound edges are widely separated and are later brought together with some type of closure material; the wounds may require a drainage device to promote quick healing.
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 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 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing.
The wound is 3 × 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 cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.
A nurse is providing care to a client who has been admitted to the health care facility with a cyst in the sebaceous gland on the chest. When obtaining the client's history, the client asks, "What do these sebaceous glands do?" What would the nurse incorporate into the response? - They produce melanin responsible for skin pigmentation. - They lubricate outer layer of skin. - They transport sweat to the outer skin surface. - They contribute to a characteristic body odor.
They lubricate outer layer of skin. Explanation: The function of sebaceous glands is to lubricate the skin's outer layer by producing sebum. Sebaceous glands are found in greatest concentration over the head and upper chest. Eccrine glands help to transport sweat to the outer skin surface. Apocrine glands produce sweat that contributes to a characteristic body odor when bacteria decompose the secretions. Melanocytes produce melanin, which is responsible for skin pigmentation.
A nurse is caring for a client who has undergone a below-the-knee amputation of the left leg. The surgeon is preparing to remove the initial surgical dressing and asks the nurse to obtain dressings and elastic bandages in preparation for removal. The nurse understands that which statement best explains the rationale for using the elastic bandages? - The wraps help approximate wound edges. - The wraps help prevent abscess formation. - They provide light support to the area. - They facilitate closure of acute wounds.
They provide light support to the area. Explanation: Elastic bandages used to provide light support to an area or to secure dressings. Elastic bandage strips do not help approximate wound edges, facilitate closure of acute wounds, or prevent abscess formation. Wound closure strips are applied to wounds to approximate wound edges and promote healing. Cyanoacrylate glue can be used to close acute wounds in certain situations. Packing allows healing from the base of the wound to the surface, helping prevent abscess formation.
A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe the client's wound? - a clean separation of skin and tissue with smooth, even edges - a wound in which the surface layers of the skin are scraped away - a shallow crater in which skin or mucous membrane is missing - a separation of skin and tissue in which the edges are torn and irregular
a clean separation of skin and tissue with smooth, even edges Explanation: The nurse can describe a wound caused by a sharp knife as an incision wound with clean separation of skin and tissue with smooth, even edges. Ulceration is a shallow crater in which skin or mucous membrane is missing. An abrasion is a wound in which the surface layers of the skin have been scraped away. A laceration is the separation of skin and tissue in which the edges are torn and irregular.
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 client who must remain on his back for long periods of time - a client who lies on wrinkled sheets - a client sitting in a chair who slides down - a client who lifts himself up on his elbows
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. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.
The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? - a critical care client - a newborn - an older client with arthritis - a client with cardiovascular disease
a critical care client Explanation: Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client.
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? - an otic curette - a small plastic ruler - a sterile tongue blade lubricated with water soluble gel - a sterile, flexible applicator moistened with saline
a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? - a wound healing naturally that becomes infected. - a surgical incision with sutured approximated edges - a wound left open for several days to allow edema to subside - a large wound with considerable tissue loss allowed to heal naturally
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. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.
The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. - an older adult who is confined to bed - a client who is taking corticosteroid drugs - a 10-year-old client with a surgical incision - a client who eats a diet high in vitamins A and C - a client with a peripheral vascular disorder - a client who is obese
an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drugs Explanation: There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure injury formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client. A client who eats a diet high in vitamins A and C would not be at risk for delayed wound healing. A 10-year old client with a surgical incision would not be at risk for delayed wound healing
A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? - assisting the client in moving to prevent strain on the suture line - administering pain medications on a p.r.n. and regular basis - preventing scar formation so it does not limit joint movement - telling the client that a mild fever is a normal response
assisting the client in moving to prevent strain on the suture line Explanation: The proliferative phase of wound healing begins within 2 to 3 days of the injury. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations. Pain medication assists with the pain and not with the wound healing process. Fever is not a normal response. A scar will occur later in the wound healing process and usually does not limit the joint movement.
A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? - avulsion - contusion - laceration - puncture
avulsion Explanation: An avulsion involves the stripping away of large areas of tissue, leaving cartilage and bone exposed. Therefore the nurse will document this assessment finding as an avulsion. A puncture is an opening of the skin caused by a narrow, sharp, pointed object. A laceration is the separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore the nurse would not document the finding as a puncture, laceration, or contusion.
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? - enzymatic debridement - autolytic debridement - biosurgical debridement - mechanical debridement
biosurgical debridement Explanation: In biosurgical debridement, fly larvae are used to clear the wound of necrotic tissue. This is accomplished by 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, as in surgical debridement
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 with a new gauze for each stroke - cleanse the wound from the outer area toward the inner area - 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 Explanation: When cleansing a wound, the nurse should use a new gauze or swab on each downward stroke of the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside.
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? - exerting equal, but not excessive, tension with each turn of the bandage - wrapping distally to proximally - elevating and supporting the stump - keeping the bandage free of gaps between turn
elevating and supporting 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 nurse is caring for a client with draining wounds. The nurse needs to apply a dressing of a highly absorbent nature. Which type of dressing should the nurse use for this client? - hydrocolloid - bandage - transparent - gauze
gauze Explanation: Gauze dressing is ideal for covering fresh wounds because of its highly absorbent nature. Gauze is applied to fresh wounds that are likely to bleed or wounds that exude drainage. The nurse uses a hydrocolloid dressing when caring for a client with superficial burn wounds; hydrocolloid dressings are self-adhesive, opaque, air- and water-occlusive wound coverings that keep wounds moist. A transparent dressing allows the nurse to assess a wound without removing the dressing; transparent dressings are especially used for peripheral and IV insertion sites. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.
A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing of a highly absorbent nature. Which type of dressing should the nurse use for this client? - hydrocolloid - gauze - transparent - bandage
gauze Explanation: Gauze dressing is ideal for covering fresh wounds because of its highly absorbent nature. Gauze is applied to fresh wounds that are likely to bleed or wounds that exude drainage. The nurse uses a hydrocolloid dressing when caring for a client with superficial burn wounds; hydrocolloid dressings are self-adhesive, opaque, air- and water-occlusive wound coverings that keep wounds moist. A transparent dressing allows the nurse to assess a wound without removing the dressing; transparent dressings are especially used for peripheral and IV insertion sites. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.
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? - adhesive strips with eyelets - gauze - hydrocolloid - transparent
gauze Explanation: Gauze dressings absorb blood or drainage. Transparent dressings are used to protect intravenous insertion sites. Hydrocolloid dressings are used to used keep a wound moist. Adhesive strips with eyelets are used to secure a gauze dressing that needs frequent changing.
The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing? - maturation phase - proliferation phase - inflammatory phase - hemostasis phase
hemostasis phase Explanation: Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and release growth factors. The proliferation phase is the regenerative phase, in which granulation tissue is formed. The maturation phase involves collagen remodeling.
When treating a client for a sprained ankle, the nurse wraps the client's ankle in a bandage. What is the purpose of wrapping the client's ankle in a bandage? - maintains a moist environment - limits movement in the wound area - holds the medication in place - protects the wound from further injury
limits movement in the wound area Explanation: The nurse wraps a bandage over the client's sprained ankle in order to limit movement in the wound area to promote healing. Bandages are also used to hold dressings in place, especially when tape cannot be used or the dressing is extremely large. Bandages also support the area around a wound or injury to reduce pain. A dressing is used to hold medication in place, maintain a moist environment, and protect the wound from further injury.
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? - notify the physician and prepare for surgery - document the assessments and intervention - reinforce the dressing with additional layers - administer pain medications intramuscularly
notify the physician and prepare for surgery Explanation: Protrusion of the intestines through an opened wound is evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required. Pain medication and documentation are also important. If necessary, the nurse should reinforce the dressing while waiting for surgery.
A client at a health care facility who underwent an appendectomy says to the nurse that he feels like something has "given way." On inspecting the surgical wound, the nurse notes pinkish drainage on the dressing. What intervention should the nurse perform in this case? - informing the head nurse immediately about the client's condition - positioning the client to put the least strain on the operated area - placing sterile dressings moistened with normal saline over the area - inspecting the wound to determine the extent of the secretion
positioning the client to put the least strain on the operated area Explanation: If wound disruption is suspected, the nurse should position the client to put the least strain on the operated area. The nurse should inform the physician immediately rather than informing the head nurse first. If evisceration occurs, the nurse places sterile dressings moistened with normal saline over the protruding organs and tissues. The nurse must be alert for signs and symptoms of impaired blood flow, such as swelling, localized pallor or a mottled appearance, and coolness of the tissue in the area around the wound. Inspecting the wound to determine the extent of the secretion may not be an appropriate action in this case.
Which condition is an indication for the use of negative pressure wound therapy? - pressure injuries - malignant wounds - wounds with fistulas to body cavities - bone infections
pressure injuries Explanation: Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure injuries; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin.
The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot and injured the worker's foot. What type of injury does the nurse anticipate? - puncture - contusion - avulsion - incision
puncture Explanation: A puncture is an opening of the skin caused by a narrow, sharp, pointed object such as a nail. Therefore the nurse documents this finding as a puncture. An incision is a clean separation of skin and tissue with smooth, even edges. In an avulsion, large areas of skin and underlying tissue have been stripped away. An abrasion involves stripping of the surface layers of skin. A contusion is an injury to soft tissue. Therefore the nurse does not document the finding as an incision, avulsion, or contusion.
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 - decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound - marked by vasodilation and phagocytosis as the body works to clean the wound - the onset of vasoconstriction, platelet aggregation, and clot formation
reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization Explanation: In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing, hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.
A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document? - serosanguineous - sanguineous - serous - purulent
serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.
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 II pressure injury - stage I pressure injury - stage III pressure injury - stage IV pressure injury
stage II pressure injury Explanation: Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.
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 I - stage IV - stage III
stage III Explanation: Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, or muscle should be seen. Stage I involves intact skin with non-blanchable redness. Stage II involves a partial tissue loss, such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? - transparent - hydrocolloid - bandage - gauze
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. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. A hydrocolloid dressing helps keep the wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.
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? - transparent film - 2 × 2 in (5 × 5 cm) gauze - hydrocolloid dressing - hydrogel sheet
transparent film Explanation: To secure an IV catheter, the nurse uses a transparent film. The transparency film allows visualization of the IV site, is self-adhesive, and protects against contamination. The 2 × 2 in (5 × 5 cm) gauze dressing does not allow visualization of the IV site and does not protect against moisture. The hydrocolloid dressing does not allow visualization of the IV site and is best used in wounds with light to moderate drainage. Hydrogel sheets are not an appropriate dressing for an IV site. They do not allow visualization of the IV site and are best used in partial- and full-thickness wounds, burns, dry wounds, wounds with minimal exudate, necrotic wounds, and infected wounds.
