Chapter 33: Skin Integrity and Wound Care
A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?
An infant's skin and mucous membranes are easily injured and at risk for infection.
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.
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
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 bestaction by the nurse at this time?
Discontinue the therapy and assess the client.
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.)
Pin the tails to the belt of the T-binder. Fasten the crossbar around the waist. Pass the tails through the client's legs.
A postoperative client is recovering from a bowel resection. While the nurse is assisting the client with a transfer, the client states "I feel like something just popped." After returning the client safely to bed, which is the nurse's best action?
Promptly assess for dehiscence
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 registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?
To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?
To splint the area when engaging in activity
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 would recognize which client as being particularly susceptible to impaired wound healing?
an obese woman with a history of type 1 diabetes