Chapter 32: Skin Integrity PrepU

In the older adult client, wrinkling is related to: a. loss of circulation. b. loss of fat. c. loss of elasticity. d. loss of protein.

c. loss of elasticity.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? a. Administer the prescribed analgesic. b. Notify the health care provider of the pain. c. Document the pain and vital signs. d. Assess the client's wound and vital signs.

d. Assess the client's wound and vital signs.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? a. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. b. Clean the wound from the top to the bottom and from the center to outside. c. Clean the wound in a circular pattern, beginning on the perimeter of the wound. d. Use clean technique to clean the wound.

b. Clean the wound from the top to the bottom and from the center to outside.

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. 1. Use the same swab for both wound sites. 2. Insert a swab into the wound. 3. Place the swab in the culture tube when done. 4. Tap the outside of the culture tube with the swab before placing it in the tube. 5. Press and rotate the swab several times over the wound surfaces. 6. Touch the swab to the intact skin at the wound edges.

2, 3, and 5 are correct

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse? a. Leave the therapy on for 10 more minutes and return to remove it after that time. b. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. c. Assist the client to get out of bed and sit up in a chair for a short while. d. Explain to the client that this is not possible because of the health care provider's prescription.

b. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? a. Scarring, sutures, and wound care b. Tetanus, infection, wound care, and pain control c. Tetanus, being able to walk, and scarring d. Prevention of recurring infection, ability to work, and wound care

b. Tetanus, infection, wound care, and pain control

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? a. The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. b. The wound is 3 × 5 cm, with yellow tissue covering the entire wound. c. The wound is a 3 × 5-cm blood-filled blister. d. The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible.

b. The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a. a large wound with considerable tissue loss allowed to heal naturally b. a surgical incision with sutured approximated edges c. a wound healing naturally that becomes infected. d. a wound left open for several days to allow edema to subside

b. a surgical incision with sutured approximated edges

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? a. "Dehiscence is the softening of tissue due to excessive moisture." b. "Dehiscence is a total separation of the wound with protrusion of the viscera through it." c. "Dehiscence is when a wound has partial or total separation of the wound layers." d. "Dehiscence is not anything that you need to worry about."

c. "Dehiscence is when a wound has partial or total separation of the wound layers."

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them? a. Apply a warm compress to the surgical staples and allow the dried blood to melt. b. Go ahead and remove the staples as they will pop up and out of the skin. c. Apply moist saline compresses to loosen crusts before attempting to remove the staples. d. Notify the health care provider of the dried blood and wait for a prescription to proceed.

c. Apply moist saline compresses to loosen crusts before attempting to remove the staples.

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? a. "Reinforced adhesive skin closures will hold my wound together until it heals." b. "I will not remove the staples myself." c. "After delivery, I will have sutures in place." d. "I may have staples in place for a number of days."

a. "Reinforced adhesive skin closures will hold my wound together until it heals."

A full-thickness or third-degree burn develops a leathery covering called a(an): a. eschar. b. static. c. abrasion. d. erythema.

a. eschar.

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? a. If there is contamination of dirt and debris b. The event leading up to the trauma c. The status of the client's tetanus immunization d. Staging the wound for assessment

c. The status of the client's tetanus immunization

Which is not considered a skin appendage? a. Sebaceous gland b. Hair c. Eccrine sweat glands d. Connective tissue

d. Connective 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? a. puncture b. contusion c. incision d. avulsion

b. contusion

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? "The surgeon will leave your wound open intentionally for a period of time." "The margins of your wound are not in direct contact." "Very little scar tissue will form." "This is a complex reparative process."

"Very little scar tissue will form."

The nurse is using the Braden Scale to determine a client's risk for pressure injuries. What criteria will the nurse assess? Select all that apply. 1. friction 2. sensory perception 3. nutrition 4. ability 5. age

1, 2, 3, and 4 are correct

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. 1. a 10-year-old client with a surgical incision 2. a client who is taking corticosteroid drugs 3. an older adult who is confined to bed 4. a client who eats a diet high in vitamins A and C 5. a client who is obese 6. a client with a peripheral vascular disorder

2, 3, 5, and 6 are correct

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? a. Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. b. Apply skin barrier only on the right side of the wound over the irritation. c. Apply skin barrier over the area of irritation to prevent further injury. d. Apply skin barrier only on the side of the wound without any irritation.

a. Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? a. As a stage IV pressure injury b. As a stage III pressure injury c. As a stage II pressure injury e. As a stage I pressure injury

a. As a stage IV pressure injury

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. a client sitting in a chair who slides down b. a client who lies on wrinkled sheets c. a client who must remain on his back for long periods of time d. a client who lifts himself up on his elbows

a. a client sitting in a chair who slides down

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? a. Discard the swab and inform the health care provider that the wound is too infected to culture b. Discard the swab, clean the wound with a non-antimicrobial cleanser, and obtain another swab c. Obtain the swab and then clean the wound d. Obtain the swab as prescribed and send it to the lab for culture

b. Discard the swab, clean the wound with a non-antimicrobial cleanser, and obtain another swab

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice? a. The nurse must diligently apply the principles of asepsis. b. Sterility must be maintained throughout the procedure. c. It is appropriate to use clean technique during this procedure. d. The nurse should apply chlorhexidine or an alternative disinfectant to the wound bed.

c. It is appropriate to use clean technique during this procedure.

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? a. laceration b. avulsion c. incision d. abrasion

c. incision

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? a. "I will apply a dressing at the end of the drain to catch any drainage." b. "I will check and empty the drain every 6 hours." c. "I will alternate between positive and negative pressure every 2 hours." d. "I will squeeze the chamber and apply the cap to maintain negative pressure."

d. "I will squeeze the chamber and apply the cap to maintain negative pressure."

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a. a wound left open for several days to allow edema to subside b. a wound healing naturally that becomes infected. c. a large wound with considerable tissue loss allowed to heal naturally d. a surgical incision with sutured approximated edges

d. a surgical incision with sutured approximated edges

TRUE OR FALSE? A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: a. evisceration. b. dehiscence. c. herniation. d. infection.

b. dehiscence.

The nurse would recognize which client as being particularly susceptible to impaired wound healing? a. a client whose breast reconstruction surgery required numerous incisions b. A client who is NPO (nothing by mouth) following bowel surgery c. an obese woman with a history of type 1 diabetes d. a man with a sedentary lifestyle and a long history of cigarette smoking

c. an obese woman with a history of type 1 diabetes

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? a. FLACC scale b. Glascow scale c. Morse scale d. Braden scale

d. Braden scale

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? a. Green beans b. Banana c. Pasta salad d. Fish

d. Fish

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery? a. period during which new cells fill and seal a wound b. process by which damaged cells recover and reestablish normal function c. physiologic defense immediately after the tissue injury d. period during which the wound undergoes changes and maturation

d. period during which the wound undergoes changes and maturation

A nurse is caring for a post-surgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider? a. foul-smelling drainage that is grayish in color b. large amounts of drainage that is clear and watery and has no smell c. small amount of drainage that appears to be mostly fresh blood d. copious drainage that is blood-tinged

a. foul-smelling drainage that is grayish in color

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? a. "You will receive medication through this device." b. "This drain minimizes the chance for bacteria to enter the surgical site." c. "It provides a way to remove drainage and blood from the surgical wound." d. "The bulb-like system will stay in place permanently after your mastectomy."

c. "It provides a way to remove drainage and blood from the surgical wound."

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. 1. Cyanosis 2. Decreased radial pulse 3. Fingers with quick capillary refill 4. No finger numbness or tingling 5. Warm hand

3, 4, and 5 are correct

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely: a. third degree or full thickness b. fourth degree or fat layer c. second degree or partial thickness d. first degree or superficial

c. second degree or partial thickness

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a. A child's skin becomes less resistant to injury and infection as the child grows. b. An individual's skin changes little over the life span. c. In children younger than 2 years, the skin is thicker and stronger than in adults. d. An infant's skin and mucous membranes are easily injured and at risk for infection.

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

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? a. Stage III b. Stage IV c. Stage I d. Stage II

d. Stage II

What intervention should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply. 1. client repositioning with a lift 2. proper client nutrition 3. pressure redistribution support surfaces 4. 2-hour turn schedule 5. pillow placed under knees 6. head of bed positioned at 45 degrees

1, 2, 3, and 4 are correct

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply. 1. elevate the head of the bed 90 degrees four times daily 2. pull the client up in bed as needed 3. turn the client every 2 hours when the client is in bed 4. encourage the client to take fluids every 2 hours 5. provide incontinent care every 2 hours and as needed

3, 4, and 5 are correct

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 what type of injuries would the nurse be alert? a. Broken left ankle, bruising, and dehydration and elevated thrombocytes b. Soft tissue damage, broken left ankle, concussion, bruising, and abrasions c. Broken left ankle, concussion, bruising, and abrasions d. Soft tissue damage, broken left ankle, bruising, and dehydration

a. Broken left ankle, bruising, and dehydration and elevated thrombocytes

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? a. removing dead or infected tissue to promote wound healing b. stimulating the wound bed to promote the growth of granulation tissue c. removing excess drainage and wet tissue to prevent maceration of surrounding skin d. removing purulent drainage from the wound bed in order to accurately assess it

a. removing dead or infected tissue to promote wound healing

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? a. use pillows to maintain a side-lying position as needed b. place a foot board on the bed c. elevate the head of the bed 90 degrees d. provide incontinent care every 4 hours as needed

a. use pillows to maintain a side-lying position as needed

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? a. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles. b. Administer analgesics 30 minutes prior to the treatment to act on pain receptors. c. Use an aquathermia pad during the treatment to create heat and circulate the water. d. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue.

b. Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? a. assessing for impaired blood flow to the area of evisceration. b. applying sterile dressings with normal saline over the protruding organs and tissue c. contacting the surgeon d. monitoring for pallor and mottled appearance of the wound

b. applying sterile dressings with normal saline over the protruding organs and tissue

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? a. The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound. b. The client's size limits his activity level. c. Adipose tissue is poorly vascularized. d. Obesity is linked to impaired white blood cell function.

c. Adipose tissue is poorly vascularized.

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? a. "This is a complex reparative process." b. "The margins of your wound are not in direct contact." c. "The surgeon will leave your wound open intentionally for a period of time." d. "Very little scar tissue will form."

d. "Very little scar tissue will form."

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? a. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. b. The nurse places the heating pad under the client's neck. c. The nurse uses a safety pin to attach the pad to the bedding. d. The nurse covers the heating pad with a heavy blanket.

a. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? a. Herniation of the wound b. Infection of the wound c. Evisceration of the viscera d. Dehiscence of the wound

d. Dehiscence of the wound

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? a. Discontinue the therapy and assess the client. b. Document the findings in the client's medical record. c. Gently rub and massage the area to warm it up. d. Notify the health care provider of the findings.

a. Discontinue the therapy and assess the client.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? a. "Have you had any recent illnesses?" b. "Do you experience incontinence?" c. "Do you use any lotions on your skin?" d. "How many meals a day do you eat?"

b. "Do you experience incontinence?"

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? a. "This is normal tissue." b. "Necrotic tissue is devitalized tissue that must be removed to promote healing." c. "That is called slough, and it will usually fall off." d. "You are seeing undermining, a type of tissue erosion."

b. "Necrotic tissue is devitalized tissue that must be removed to promote healing."

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? a. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." b. "Your wound will heal slowly as granulation tissue forms and fills the wound." c. "As soon as the infection clears, your surgeon will staple the wound closed." d. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."

b. "Your wound will heal slowly as granulation tissue forms and fills the 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? a. serous b. serosanguineous c. purulent d. sanguineous

b. serosanguineous

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother: that lanugo is hair of a different color that is permanent. a. to never trim the baby's nails due b. to susceptibility to infection. c. to apply sunscreen when exposed to ultraviolet rays. d. to only use cloth diapers, since disposable ones can cause eczema.

c. to apply sunscreen when exposed to ultraviolet rays.

The nurse is caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states, "My pain medication is effective, but will this pain ever get better and go away?" Which response is correct? a. "If the pain does not subside by this time tomorrow, you will need to be screened for the development of chronic pain." b. "It is unusual for you to still have severe pain. I will contact your surgeon." c. "If the prescribed analgesics are controlling the pain, we do not worry about the severity of the pain." d. "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe."

d. "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe."

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. an otic curette b. a sterile tongue blade lubricated with water soluble gel c. a small plastic ruler d. a sterile, flexible applicator moistened with saline

d. a sterile, flexible applicator moistened with saline

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? a. lubricating the area with skin oil b. pulling the client up from under the arms c. preventing the client from sliding in bed d. improving the client's hydration

c. preventing the client from sliding in bed

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? a. Reduce the time interval between dressing changes. b. Assure that the packing material is completely saturated when placed in the wound. c. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. d. Use less packing material.

a. Reduce the time interval between dressing changes.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? a. The nurse works outward from the wound in lines parallel to it. b. The nurse swabs the wound from the bottom to the top. c. The nurse swabs the wound with povidone-iodine to fight infection in the wound. d. The nurse uses friction when cleaning the wound to loosen dead cells.

a. The nurse works outward from the wound in lines parallel to it.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? a. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown b. A superficial partial-thickness burn, which can appear dry and leathery c. Superficial, which may be pinkish or red with no blistering d. May vary from brown or black to cherry red or pearly white; bullae may be present

a. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

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? a. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. b. Rotate the swab several times over the wound surface to obtain an adequate specimen. c. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. d. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

b. Rotate the swab several times over the wound surface to obtain an adequate specimen.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? a. Cutting with a sharp instrument with wound edges in close approximation with correct alignment b. Tearing of a structure from its normal position c. Tearing of the skin and tissue with some type of instrument; tissue not aligned d. Puncture of the skin

b. Tearing of a structure from its normal position

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? a. "I must wait 15 minutes between applications of cold therapy." b. "I should keep this on my ankle until it is numb." c. "I will put a layer of cloth between my skin and the ice pack." d. "I can let this stay on my ankle an hour at a time."

c. "I will put a layer of cloth between my skin and the ice pack."

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? a. Use an aquathermia pad during the treatment to create heat and circulate the water. b. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. c. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles. d. Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

d. Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

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? a. fistula b. hemorrhage c. dehiscence d. evisceration

d. evisceration

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown? a. Implement a 2-hour repositioning schedule b. Frequently orient client to place and situation c. Massage skin surfaces daily, especially areas under pressure and bony prominences d. Perform passive range-of-motion exercises

a. Implement a 2-hour repositioning schedule

The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply. 1. A nurse places a drainage dressing around a drain insertion site. 2. A nurse places a transparent dressing over an ABD pad to help keep the wound dry. 3. A nurse places a transparent dressing over a central venous access device insertion site. 4. A nurse places a Surgipad directly over an incision. 5. A nurse uses aseptic techniques when changing a dressing. 6. A nurse applies Telfa to a wound to keep drainage from passing through to a secondary dressing.

1, 2, and 4 are correct

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? a. Local capillary pressure must be lower than external pressure. b. The heart must be able to pump adequately. c. Arteries and veins must be patent and functioning well. d. The volume of circulating blood must be sufficient.

a. Local capillary pressure must be lower than external pressure.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? a. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. b. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c. Carefully pick the crusts off the sutures with the forceps before removing them. d. Do not attempt to remove the sutures because the wound needs more time to heal.

a. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? a. The nurse uses wet-to-dry dressings continuously. b. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. c. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. d. The nurse packs the wound cavity tightly with dressing material.

b. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

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? a. "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." b. "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." c. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." d. "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider."

c. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

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? a. Desiccation b. Maceration c. Necrosis d. Evisceration

d. Evisceration

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? a. Cleanse the wound after obtaining the wound culture. b. Utilize the culture swab to obtain cultures from multiple sites. c. Stroke the culture swab on surrounding skin first. d. Keep the swab and the inside of the culture tube sterile.

d. Keep the swab and the inside of the culture tube sterile.

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? a. a dressing with a non-adherent coating b. a gauze dressing pre-medicated with antibiotics c. a gauze dressing precut halfway to fit around the IV line d. a transparent film

d. a transparent film

A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? a. tertiary intention b. primary intention c. desiccation d. secondary intention

d. secondary intention

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? a. gauze b. hydrocolloid c. bandage d. transparent

d. transparent