(Fund Ch 32) PrepU

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. contusion b. incision c. puncture d. avulsion

a. 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.

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

a. 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? a. preventing the client from sliding in bed b. pulling the client up from under the arms c. improving the client's hydration d. lubricating the area with skin oil

a. 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.

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

b. "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. It does not provide a route for medication administration or decrease the chance for infection, nor does it stay attached permanently.

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? a. keeping the bandage free of gaps between turn b. wrapping distally to proximally c. elevating and supporting the stump d. exerting equal, but not excessive, tension with each turn of the bandage

c. 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.

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. avulsion b. laceration c. incision d. abrasion

c. 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.

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 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.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: a. prickly heat. b. milia. c. lanugo. d. acne vulgaris.

milia. Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.

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

a. "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.

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

a. "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.

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? a. Albumin 2.8 mg/dL (28.0 g/L) b. Hemoglobin A1C 5% c. White blood cell count 14,800 mm3 (14.8 x 109/L) d. Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L)

a. 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? a. Assess the client's wound and vital signs. b. Administer the prescribed analgesic. c. Document the pain and vital signs. d. Notify the health care provider of the pain.

a. 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.

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. Evisceration d. Necrosis

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

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

a. Keep the swab and the inside of the culture tube sterile. The swab and the inside of the culture tube should be kept sterile. 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

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

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

a. 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 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. Tearing of a structure from its normal position b. Cutting with a sharp instrument with wound edges in close approximation with correct alignment c. Puncture of the skin d. Tearing of the skin and tissue with some type of instrument; tissue not aligned

a. Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? a. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. b. The nurse uses wet-to-dry dressings continuously. 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.

a. 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.

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

a. applying sterile dressings with normal saline over the protruding organs and tissue The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

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. "Very little scar tissue will form." c. "The margins of your wound are not in direct contact." d. "The surgeon will leave your wound open intentionally for a period of time."

b. "Very little scar tissue will form." Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

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

b. 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.

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. Evisceration of the viscera b. Dehiscence of the wound c. Infection of the wound d. Herniation of the wound

b. Dehiscence of the wound 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. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

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? a. Wet to dry b. Hydrocolloid c. Negative wound pressure therapy d. Telfa

b. Hydrocolloid The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement. Telfa pads are nonstick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement.

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen? a. Risk for Infection related to wound b. Impaired Skin Integrity related to open wound c. Knowledge Deficit regarding wound care related to laceration d. Pain related to wound sustained by knife

b. Impaired Skin Integrity related to open wound Impaired skin integrity best describes the minor laceration. While the other diagnoses, Pain, Knowledge Deficit, and Risk for Infection, are all possible as a result of the laceration, there is no indication in the scenario that they are the case.

The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, the nurse will incorporate which nursing measure? a. Perform the dressing change during mealtime to allow for distraction. b. Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. c. Perform the dressing change when the client is fatigued after physical therapy. d. Plan to administer a prescribed analgesic immediately prior to the dressing change.

b. Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. The nurse should plan to administer a prescribed analgesic 30 to 45 minutes prior to changing the dressing. Analgesic administration immediately prior to a dressing change will not allow the analgesic to reach its maximum pain control impact. When clients are fatigued, the sensation of pain may be greater. Also, plan to change the dressing midway between meals so that the client's appetite and mealtimes are not disturbed.

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 action? a. Cleanse the area around the cap with alcohol for 30 seconds before removing it. b. Recompress the drain before replacing the cap. c. Don sterile gloves before manipulating the cap of the drain. d. Pin the drain to the client's gown after pulling the tubing taut.

b. Recompress the drain before replacing the cap. Recompressing the drain after replacing the cap would force air and exudate into the client, causing pain and posing an infection risk. Gloves are necessary for this procedure, but they do not need to be sterile. It is unnecessary to cleanse the area around the cap with alcohol. It is important that the tubing should not be under tension.

Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan? a. To facilitate adequate rest, disconnect NPWT each night between 2200 and 0700. b. Record the quantity of drainage once per shift and document on the intake and output record. c. Remove the transparent dressing if a leak is noted. d. Change the wound dressing daily, or more frequently if excessive output is noted.

b. Record the quantity of drainage once per shift and document on the intake and output record. Output from NPWT should be recorded once per shift. Leaks can often be resolved by reinforcing the dressing and the treatment should continue 24 hrs/day. Dressings are normally changed two to three times per week.

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? a. Apply an occlusive pressure dressing after removing the staples. b. Stop removing staples and inform the surgeon c. Stop removing staples and apply an abdominal pad over the incision. d. Apply adhesive wound closure strips after each staple is removed.

b. 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 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? a. Muscle layer b. Subcutaneous tissue c. Dermis d. Epidermis

b. Subcutaneous tissue The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. a. False b. True

b. True A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

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? a. Magnesium b. Zinc c. Vitamin B12 d. Vitamin A

b. Zinc Adequate intake of iron, copper, and zinc is important to prevent abnormal pigmentation and changes in nails and hair.

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? a. tertiary intention b. secondary intention c. maturation d. primary intention

b. 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? a. sanguineous b. serosanguineous c. purulent d. serous

b. 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 is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? a. "I may have staples in place for a number of days." b. "After delivery, I will have sutures in place." c. "Reinforced adhesive skin closures will hold my wound together until it heals." d. "I will not remove the staples myself."

c. "Reinforced adhesive skin closures will hold my wound together until it heals." After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples. Reinforced adhesive skin closures are not strong enough to hold this type of wound together.

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

c. "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.

Which action should the nurse perform when applying negative pressure wound therapy? a. Increase the negative pressure setting until drainage is brisk. b. Irrigate the wound thoroughly using normal saline and clean technique. c. Cut foam to the shape of the wound and place it in the wound. d. Test the seal of the completed dressing by briefly attaching it to wall suction.

c. Cut foam to the shape of the wound and place it in the wound. When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

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. The volume of circulating blood must be sufficient. b. Arteries and veins must be patent and functioning well. c. Local capillary pressure must be lower than external pressure. d. The heart must be able to pump adequately.

c. Local capillary pressure must be lower than external pressure. Local capillary pressure must be higher than external pressure for adequate skin perfusion.

A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product? a. The dressing provides a sterile wound environment. b. The dressing may safely be left in place for up to 10 days. c. The dressing allows oxygen exchange between the wound and environment. d. The dressing allows for absorption of drainage.

c. The dressing allows oxygen exchange between the wound and environment. Transparent films allow for oxygen exchange between the wound and the environment. They do not absorb any drainage and they are normally left in place for up to 72 hours. Sterility is not conferred simply by the application of a wound dressing.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? a. To remain in bed for the next 4 hours b. To ambulate using a cane or walker c. To splint the area when engaging in activity d. To turn the head away from the area whenever coughing

c. To splint the area when engaging in activity To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention? a. Stop irrigating when the solution from the wound turns light pink. b. Apply petroleum jelly to the periwound skin to protect it from the irrigation solution. c. Use clean technique instead of sterile technique if the wound is closed. d. If new bleeding is noted, continue irrigation cautiously and then notify the health care provider.

c. Use clean technique instead of sterile technique if the wound is closed. Clean technique can be used on a closed wound. When the solution from the wound turns clear, the irrigation should be discontinued. If bleeding is noted that was not previously there, the nurse should stop the irrigation and notify the health care provider. There is no need to apply petroleum jelly to the periwound skin.

The nurse would recognize which client as being particularly susceptible to impaired wound healing? a. a man with a sedentary lifestyle and a long history of cigarette smoking 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 client whose breast reconstruction surgery required numerous incisions

c. an obese woman with a history of type 1 diabetes Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

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

c. an older adult who is confined to bed f. a client with a peripheral vascular disorder d. a client who is obese e. a client who is taking corticosteroid drugs There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure injury formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client. A client who eats a diet high in vitamins A and C would not be at risk for delayed wound healing. A 10-year old client with a surgical incision would not be at risk for delayed wound healing.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a. potassium supplements b. antihypertensive drugs c. corticosteroids d. laxatives

c. 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 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 Partial-thickness burns may be superficial or moderate to deep. A superficial partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good example. Moderate to deep partial-thickness burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present. The full-thickness burn appears dry and leathery.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document? a. sanguineous b. purulent c. serosanguineous d. serous

c. serosanguineous Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.

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

c. 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.

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

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

d. "Necrotic tissue is devitalized tissue that must be removed to promote healing." The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. 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 pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a. An individual's skin changes little over the life span. b. A child's skin becomes less resistant to injury and infection as the child grows. 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. An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? a. Red classification b. Unstageable c. Yellow classification d. Black classification

d. Black classification A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System.

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

d. 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.

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. Do not attempt to remove the sutures because the wound needs more time to heal. 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. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

d. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

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

d. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

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. a newborn b. a client with cardiovascular disease c. an older client with arthritis d. a critical care client

d. a critical care client Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a. a wound healing naturally that becomes infected. b. a wound left open for several days to allow edema to subside 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 Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.

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. dehiscence b. fistula c. hemorrhage d. evisceration

d. 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.

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? a. hydrogel b. alginate c. transparent film d. hydrocolloid dressing

d. hydrocolloid dressing 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.

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

d. to apply sunscreen when exposed to ultraviolet rays. Sunscreen is necessary to protect against damage caused by ultraviolet rays.

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

d. use pillows to maintain a side-lying position as needed Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.