Chapter 32 Prep U (Exam 2)

Which client(s) is considered at risk for skin alterations? Select all that apply.

- A teenager with multiple body piercings. - A client receiving radiation therapy. - A client with diabetes. Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a sexual relationship with multiple gay male partners would also place a client at risk for HIV and skin alterations, but this client is in a monogamous relationship. Cardiac monitoring does not place a client at risk for skin alterations.

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?

Albumin 2.8 mg/dL (28.0 g/L) An albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure injury. This indicates that the client is nutritionally deficient. The hemoglobin A1C level of 5% is a normal value. The BUN level is within normal limits. The white blood cell count is also a normal value.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs. First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

Which is not considered a skin appendage?

Connective tissue 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.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

Fish To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

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

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client?

Monitor intake and output. A client with diarrhea caused by Clostridium difficile is at risk for dehydration. As such, the priority assessments should include intake and output, skin turgor, condition of mucous membranes, and vital signs. Assessing the coccyx area for blanching should be done with shift assessments; however, circulating fluid volume takes priority. Monitoring for nausea and assessing the client's mentation is not directly related to the effects of the infectious diarrhea.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen. The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

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 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 is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

Stop removing staples and inform the surgeon If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform?

Wound irrigation With the yellow classification using the RYB wound classification system, wound irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present.

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 sitting in a chair who slides down 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 injury from shearing forces would be a client sitting in a chair who slides down.

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline 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.

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?

alginate Alginates are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue. Hydrogels are used with dry wounds or wounds with minimal drainage. Hydrocolloids are used with light to moderate drainage in wounds with necrosis or slough. Transparent dressings are used with wounds having minimal drainage, small size, and partial thickness.

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue.

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?

secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

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?

serosanguineous This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

stage II The area of redness and blister formation indicate that the client is experiencing a stage II pressure injury. A stage I pressure injury is intact but reddened. A stage III pressure injury has a shallow skin crater that extends to the subcutaneous tissue. A stage IV pressure injury is severe; the tissue is deeply ulcerated and exposes muscle and bone with the presence of necrotic tissue likely.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?

stage IV Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

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 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 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?

transparent 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.

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

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

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?" The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

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." 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.

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?

"It provides a way to remove drainage and blood from the surgical wound." The bulb-like drain allows removal of blood and drainage from the surgical site. Drainage in this system is aided by low suction, not by gravity or capillary action. It does not provide a route for medication administration, nor does it stay attached permanently.

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

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.

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 wound will heal slowly as granulation tissue forms and fills the wound." 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 applies an aquathermia pad to the back of a client with arthritis. What administration considerations should the nurse use? Select all that apply.

- Apply a bath blanket over the aquathermia pad. - Assess skin and pain level at baseline and ongoing. - Check the water level in the aquathermia unit periodically. The nurse would apply a bath blanket over the aquathermia pad to protect skin from direct contact with the heat source. Distilled water is used to the fill mark in the unit. Tap water should not be used because it leads to mineral deposits, making the machine not function properly. The heat therapy is prescribed for a certain time, usually up to 30 minutes, and then it needs to be removed for the prescribed time to prevent the development of rebound phenomenon, when excessive heat leads to tissue congestion and vasoconstriction. Leaving heat therapy in place too long also can lead to skin burns and tissue damage. The nurse would assess skin and pain level at baseline and ongoing throughout the therapy before and after application of the treatment. The aquathermia unit provides moist heat, so the nurse would check the unit to ensure that the water level is at the correct level so the matching works properly. If the water drops below its required level, permanent damage may occur.

A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For which type(s) of injury would the nurse be alert? Select all that apply.

- Broken left ankle - Bruising - Soft tissue damage - Concussion - Abrasions Skateboard related injuries that the nurse needs to assess for are a concussion and other brain injuries, broken bones, soft tissue injuries, and skin abrasions, cuts, and bruises. Symptoms of a concussion are dizziness, headaches, visual changes, loss of memory, slowed speech, and sensitivity to noise. An abrasion involves stripping of layers on the skin's surface. Soft tissue injuries include damage to the muscles, tendons, and ligaments. Dehydration can cause headaches and dizziness; however, since the client injured oneself while skateboarding a concussion should be suspected and assessed for. Because the client reported sliding on the sidewalk, the client should also be assessed for skin abrasions.

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy. Which interventions should the nurse follow to apply the T-binder? (Select all that apply.)

- Fasten the crossbar around the waist. - Pass the tails through the client's legs. - Pin the tails to the belt of the T-binder. When applying a T-binder to secure a dressing to the anus of a client who has undergone hemorrhoidectomy for piles, the nurse fastens the crossbar of the T around the waist. Then the nurse passes the single or double tails between the client's legs and pins the tails to the belt. Adhesive sanitary napkins worn inside briefs are an alternative to a T-binder for stabilizing absorbent materials. When managing a closed drain, the nurse cleans the insertion in a circular manner. After cleansing, the nurse places a precut drain sponge or gauze, which is open to its center, around the base of the drain.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

- Insert a swab into the wound. - Press and rotate the swab several times over the wound surfaces. - Place the swab in the culture tube when done. The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination.

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

- Warm hand. - Fingers with quick capillary refill. - No finger numbness or tingling. The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers. Cyanosis, pallor, coolness, numbness, tingling, swelling, or absent or diminished pulse are signs that circulation may be decreased or that nerve function is impaired.

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 promotes passive drainage into a dressing. A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform?

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?

Apply saline solution-moistened gauze over the protruding area. The first thing the nurse will do is cover the protruding intestine with a saline solution-moistened gauze. The nurse will then notify the health care provider of wound evisceration. If the protruding intestine is left open to the air, it may cause drying of the fragile tissue and necrosis to the area. The nurse should not pack anything into the wound since foreign body retention may cause complications at a later time if the gauze is not recovered. The occurrence of wound evisceration is not an expected finding and may be serious depending upon whether the protruding area is viable.

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. The skin barrier should be placed at least 1 in (2.5 cm) away from the area of irritation and should be placed on both sides of the wound. Skin barrier should not be placed over the area of irritation; it should only be placed on skin that is intact. The skin barrier should be applied to both sides of the wound as the Montgomery straps are applied to both sides of the wound on the intact skin surrounding the wound and 1 in (2.5 cm) away from any irritated or nonintact skin.

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?

Braden scale The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glasgow 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. 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.

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. 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 caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization Staging the wound is only done with pressure injuries. The presence of dirt or debris is something that will need to be addressed, but not the most important assessment. Understanding how the client stepped on the nail will need to be noted and is a possible educational opportunity for prevention, but it is not the most important assessment concern. Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defense against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.

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 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 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 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.

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?

contusion 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 review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

corticosteroids Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

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?

elevating and supporting the stump 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.

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

evisceration Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

The nurse is 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 A figure-of-eight turn is used for joints like the elbows and knees. The other answers are incorrect.

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?

hemostasis phase 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.

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

hydrocolloid Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.

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

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?

oblique The oblique position, an alternative to the side-lying position, results in significantly less pressure on the trochanter area. The nurse should not position the head of the bed above 30° unless medically contraindicated, and alternate right side, back, left side, and prone positions (when tolerated) using appropriate equipment to minimize friction and shearing.

A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?

tertiary intention Healing by tertiary intention occurs when a delay ensues between injury and wound closure. This type of healing also is referred to as delayed primary closure. It may happen when a deep wound is not sutured immediately or is purposely left open until there is no sign of infection, then closed with sutures. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the primary wound are approximated or lightly pulled together. Wounds with full-thickness tissue loss, such as deep lacerations, burns, and pressure injuries, have edges that do not readily approximate. They heal by secondary intention. The open wound gradually fills with granulation tissue.