Chapter 32: Skin Integrity and Wound Care

You are applying a saline-moistened dressing to a patient's wound. The patient asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate?

"Wounds heal better when a moist wound bed is maintained." p.943

The acute care nurse is caring for a patient whose large surgical wound is healing by secondary intention. The patient asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound." p.923

The physician has prescribed heat therapy for a patient's leg wound. The nurse is preparing the patient for the heat therapy and informs the patient that he will have warmed compresses on the leg wound for:

20 to 30 minutes p.958

The nurse should use extreme caution when applying heat therapy to which of the following patients?

A patient who is unconscious p.988

Upon assessment of the skin of a patient recovering from cardiac surgery, the nurse notes that ecchymosis is present around the incision. What are the physical findings of this condition?

A purplish discoloration due to a collection of blood in the subcutaneous tissues p.923

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red raised rash under the client's breasts. This manifestation is most consistent with which of the following conditions?

A rash related to a yeast infection p.931

You are caring for a patient who has a heavy exudating wound that needs autolytic debridement. Which of the following wound dressings/products is most appropriate to use on the wound?

An alginate dressing, such as AlgiCell p.945

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection p.921

The nurse would recognize which of the following patients as being particularly susceptible to impaired wound healing?

An obese woman with a history of type 1 diabetes mellitus p.920

Which of the following is an accurate step when applying a saline-moistened dressing on a patient's wound?

Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze. p.971

A nurse prepares to give a sitz bath to a client after perianal surgery. Which of the following would be most important for the nurse to do?

Assess for rapid pulse and facial pallor p.943

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure?

Clean the wound from the top to the bottom and center to outside. p.947

Which of the following nutrients will prevent abnormal pigmentation?

Copper p.924

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

Corticosteroids p.926

Upon responding to the patient's call bell, the nurse discovers the patient's wound has dehisced. Initial nursing management includes calling the physician and which of the following?

Covering the wound area with sterile towels moistened with sterile 0.9% saline p.964

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for

Dehiscence p.927

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline and inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth p.938

The wound care nurse evaluates a patient's wound after being consulted. The patient'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 patient's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation p.925

A nurse applies an aquathermia pad on the back of a patient with arthritis. What is the expected action that will occur with this application of heat?

Dilated peripheral blood vessels p.989

You are preparing to irrigate a patient'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. p.972

A full-thickness burn develops a leathery covering called a(an)

Eschar p.932

A woman fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. The client has a(an)

Fistula p.927

A home care nurse is visiting an older adult client. During the visit, the client's spouse sustains a minor thermal injury when cooking. The nurse intervenes, doing which of the following first?

Flush the area with copious of cool water p.956

Which of the following types of wound drainage should alert the nurse to the possibility of infection?

Foul-smelling drainage that is grayish in color p.927

In the elderly client, wrinkling is related to

Loss of elasticity p.969

A nurse is removing sutures from the surgical wound of a patient after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures p.953

Which of the following is an indication for the use of negative pressure wound therapy?

Pressure ulcers p.952

A nurse assessing the wound healing of a patient, documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

Primary intention p. 923

Upon assessment of a patient's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Proliferation phase p.924

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following?

Serosanguineous p.938

The nurse is caring for a woman has a labile carbuncle. Which of the following interventions will most likely be included in the plan of care?

Soak in a warm bath for drainage p.959

While performing a bedbath, you noted an area of tissue injury on the patient's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound?

Stage II pressure ulcer p.933

A nurse inspecting a patient's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?

Stage III p.933

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a patient with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound?

Stage III pressure ulcer p.933

A patient receiving a sitz bath complains of light-headedness to the nurse. What is the intervention that should be implemented in this situation?

Stop the sitz bath, call for help, and help the patient to the toilet to sit down. p.959

Which of the following activities should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Support the client from sliding in bed p.929

A nurse bandages the knee of a client who has recently undergone a knee surgery. Which of the following is the major purpose of the bandage?

Supports the area around the wound p.948

A nurse caring for a patient who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition?

There is an accidental separation of the wound p.927

While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record?

Unintentional, partial-thickness wound p.955

A nurse is treating the pressure ulcer of an African American patient. How would the nurse assess for deep tissue injury in this patient?

Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, and warmer or cooler as compared with adjacent tissue. p.935

You are removing a patient's dressing and encounter resistance while removing tape from the patient's skin. Which of the following strategies to remove the tape is most appropriate?

Use a silicon-based adhesive remover. p.964

During a skin assessment, the nurse recognizes the first indication that a pressure ulcer may be developing when she notices the skin is which color?

White p.932

What observation should the nurse note about a client's open wound if the wound is healing by the third-intention?

Wound edges are widely separated and brought together with closure material p.923

Dehiscence is the softening of tissue due to excessive moisture.

False p.927

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound?

Hydrocolloid dressing p.945

A nurse is providing care to a client who has been admitted to the healthcare 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?" Which of the following would the nurse incorporate into the response?

Lubricate outer layer of skin p. 921

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 p.945

Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

• Clean the wound from top to bottom. • Use a sterile applicator to apply any ointment that is ordered. • Use a new gauze for each wipe of the wound. • Avoid touching the wound bed, whether with gloves or forceps.

Which of the following processes are responsible for restoring integrity of the skin and damaged tissues when caring for a client with an open wound? Select all that apply.

• Resolution • Regeneration • Scar formation p.943

A nurse notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record?

A separation of skin and tissue in which the edges are torn and irregular p.922

You are preparing to measure the depth of a patient's tunneled wound. Which of the following implements should you use to measure the depth accurately?

A sterile, flexible applicator moistened with saline p.938

It is customary for the registered nurse to perform the initial postoperative dressing change.

False p.943

A home care nurse is visiting a client as a part of a regular visit. The client's four-year-daughter falls while playing and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress to the child's knee based on the understanding that cold achieves which effect?

Help in controlling swelling p.956

The nurse would recognize which of these devices as an open drainage system?

Penrose drain p.950

When measuring the size, depth, and wound tunneling of a patient's stage IV pressure ulcer, what action should the nurse perform first?

Perform hand hygiene p.946

A nurse is assessing a client's diabetic ulcer and notes the color of the wound's base. Which of the following would the nurse interpret as indicating a healthy wound with adequate circulation?

Pink p.924

Pressure ulcers are caused by unrelieved compression of the skin that results in damage to underlying tissues.

True p.929

A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon.

True p.950

A nurse uses enzymatic debridement to promote the healing of wounds for a client in the health care facility. For which of the following type of wounds would the nurse use this type of debridement?

Uninfected wounds p.944

An elderly client has edema of the right lower extremity with redness and clear drainage. This is most likely related to

Venous insufficiency p.923

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy for piles. Which of the following 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 p.950

A nurse is caring for a client who has recently undergone hernial surgery. The nurse knows that which of the following are possible causes of complications with regard to surgical wounds? Select all that apply.

• Insufficient protein and vitamin C intake • Weak tissue and muscular support due to obesity • Distension of the abdomen from accumulated intestinal gas p.926

An elderly patient has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the patient's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the patient's venous access site?

A transparent film p.944

What type of dressing has the advantages of remaining in place for 3 to 7 days, resulting in less interference with wound healing?

Hydrocolloid dressings p.945

A client has a small wound with moderate drainage. The nurse should apply

Hydrophilic polyurethane p.944

A physician orders a wound irrigation to apply local antiseptics to a patient's wound. Which of the following is a guideline for performing this procedure?

If the wound is closed, clean technique may be used instead of sterile technique. 946.

A physician orders the application of a warm, sterile compress to reduce edema in a patient's wound. Which of the following is a recommended step in this procedure?

Keep the dressing in place for the prescribed amount of time or up to 30 minutes. p.993

You are caring for a patient who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, you note that the packing material is dry and adheres to the wound bed. Which of the following modifications is most appropriate?

Reduce the time interval between dressing changes. p.971

A medicalsurgical nurse is assisting a wound care nurse with the debridement of a patient's coccyx wound. What is the primary goal of these nurses' action?

Removing dead or infected tissue to promote wound healing p.944

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the patient's chance of skin breakdown?

Reposition the patient on a regular basis. p.929