Chapter 32: Skin Integrity and Wound Care
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.
The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?
Impaired tissue integrity
A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?
Penrose drain
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
The nurse is caring for a client who has recently noted abnormal pigmentation in his skin. What is most likely deficient in the client's diet?
Zinc
The nurse is preparing to change a large abdominal dressing in which blood and drainage is expected. In addition to gauze, which dressing supply will the nurse gather to take in the client's room?
adhesive strips with eyelets
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
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.
The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?
"Necrotic tissue is devitalized tissue that must be removed to promote healing."
The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.
"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other."
A nurse is using the RYB wound classification system to document client wounds. Which wound would the nurse document as a Y (yellow) wound? Select all that apply.
A wound that is characterized by oozing from the tissue covering the wound A wound with drainage that is a beige color A wound that requires wound cleaning and irrigation
An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor?
Adipose tissue is poorly vascularized.
The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?
Apply a skin protectant to the skin around the incision.
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.
Which is not considered a skin appendage?
Connective tissue
Which action should the nurse perform when applying negative pressure wound therapy?
Cut foam to the shape of the wound and place it in the wound.
A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse?
Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another
When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse?
Document the findings.
Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select?
Hydrocolloid
A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?
Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement
The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what actio
Recompress the drain before replacing the cap.
During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure?
Red
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 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?
Subcutaneous tissue
A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?
Supports the area around the wound
Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply.
The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm.
A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making?
The nurse should apply adhesive wound closure strips after removing staples.
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.
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 3 × 5 cm, with yellow tissue covering the entire wound.
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
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
The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound?
an alginate dressing
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
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
corticosteroids
A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply.
covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position using sterile technique
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
A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?
mechanical debridement
A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound?
proliferation phase
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
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
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
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
A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?
undermining
