ML8 CH 32
A nurse is providing wound care for a client who has a pressure injury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options. 5. Cleanse the wound with normal saline. 2. Use nonsterile gloves. 6. Apply wound covering. 4. Apply sterile gloves. 3. Remove old dressing. 1. Give pain medication.
1. Give pain medication. 2. Use nonsterile gloves. 3. Remove old dressing. 4. Apply sterile gloves. 5. Cleanse the wound with normal saline. 6. Apply wound covering.
A client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment? A. "Do not douche for 24-48 hours before the procedure." B. "Douching is recommended so that you are clean for the examination." C. "Plan to begin douching routinely immediately after your procedure." D. "The Pap procedure includes application of a douche."
A. "Do not douche for 24-48 hours before the procedure."
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. "That is called slough, and it will usually fall off." C. "You are seeing undermining, a type of tissue erosion." 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 nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. A. "Very little scar tissue will form." B. "This is a simple reparative process." C. "The margins of your wound are widely separated." D. "Your wound will be purposely left open for a time." E. "Your wound edges are right next to each other.
A. "Very little scar tissue will form." B. "This is a simple reparative process." E. "Your wound edges are right next to each other.
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 wound will heal slowly as granulation tissue forms and fills the wound." B. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." C. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." D. "As soon as the infection clears, your surgeon will staple the wound closed."
A. "Your wound will heal slowly as granulation tissue forms and fills the wound."
A client has a fissure on her finger due to chafing. The client asks, "How long will it be painful?" The nurse explains that the inflammation phase will last: A. 3 days. B. 5 days. C. 7 days. B. 2 weeks.
A. 3 days.
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A. A Penrose drain promotes passive drainage into a dressing. B. A Penrose drain is a closed drainage system that is connected to an electronic suction device. C. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. D. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.
A. A Penrose drain promotes passive drainage into a dressing.
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? A. An infant's skin and mucous membranes are easily injured and at risk for infection. B. In children younger than 2 years, the skin is thicker and stronger than in adults. C. A child's skin becomes less resistant to injury and infection as the child grows. D. An individual's skin changes little over the life span.
A. An infant's skin and mucous membranes are easily injured and at risk for infection.
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 I pressure injury B. As a stage II pressure injury C. As a stage III pressure injury D. As a stage IV pressure injury
A. As a stage I pressure injury
What should the nurse assess before application of sitz bath therapy? Select all that apply. A. Client's ability to ambulate to the bathroom B. Client's ability to sit for 15 to 20 minutes C. Client's perineal/rectal area D. Client's need to void E. Client's serum sodium levels
A. Client's ability to ambulate to the bathroom B. Client's ability to sit for 15 to 20 minutes C. Client's perineal/rectal area D. Client's need to void
In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy? A. Every 48 to 72 hours B. Every 8 to 12 hours C. Every 12 to 24 hours D. Every 25 to 36 hours
A. Every 48 to 72 hours
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. Impaired Skin Integrity related to open wound B. Pain related to wound sustained by knife C. Knowledge Deficit regarding wound care related to laceration D. Risk for Infection related to wound
A. Impaired Skin Integrity related to open wound
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. Perform passive range-of-motion exercises C. Massage skin surfaces daily, especially areas under pressure and bony prominences D. Frequently orient client to place and situation
A. Implement a 2-hour repositioning schedule
The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. A. Insert tubing into the infusion port of the sitz bath. B. Slowly unclamp the tubing and allow the sitz bath to fill. C. Hang the bag of tepid to warm water at the client's chest height on an IV pole. D. Have the client soak for about 50 to 60 minutes. E. Ensure that the call bell is within reach. F. Fill the bowl of the sitz bath about halfway full with tepid to warm water.
A. Insert tubing into the infusion port of the sitz bath. B. Slowly unclamp the tubing and allow the sitz bath to fill. E. Ensure that the call bell is within reach. F. Fill the bowl of the sitz bath about halfway full with tepid to warm water.
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. Use less packing material. D. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.
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 uses friction when cleaning the wound to loosen dead cells. C. The nurse swabs the wound with povidone-iodine to fight infection in the wound. D. The nurse swabs the wound from the bottom to the top.
A. The nurse works outward from the wound in lines parallel to it.
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? A. To splint the area when engaging in activity B. To ambulate using a cane or walker C. To remain in bed for the next 4 hours D. To turn the head away from the area whenever coughing
A. To splint the area when engaging in activity
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. A. True B. False
A. True
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 lifts himself up on his elbows C. a client who lies on wrinkled sheets D. a client who must remain on his back for long periods of time
A. a client sitting in a chair who slides down
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A. a surgical incision with sutured approximated edges B. a large wound with considerable tissue loss allowed to heal naturally C. a wound left open for several days to allow edema to subside D. a wound healing naturally that becomes infected.
A. a surgical incision with sutured approximated edges
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? A. corticosteroids B. antihypertensive drugs C. potassium supplements D. laxatives
A. corticosteroids
A nurse is caring for a postsurgical 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. copious drainage that is blood-tinged C. Large amounts of drainage that is clear and watery and has no smell D. small amount of drainage that appears to be mostly fresh blood
A. foul-smelling drainage that is grayish in color
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. lubricating the area with skin oil C. improving the client's hydration D. pulling the client up from under the arms
A. preventing the client from sliding in bed
The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate? A. "The condition is hard to cure." B. "You will likely experience periods of increased skin outbreaks and periods of remissions." C. "You will have this disease for life." D. "Your personal health habits will dictate how well you handle this condition."
B. "You will likely experience periods of increased skin outbreaks and periods of remissions."
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. he client's size limits his activity level. B. Adipose tissue is poorly vascularized. C. Obesity is linked to impaired white blood cell function. D. The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.
B. Adipose tissue is poorly vascularized.
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. Gently rub and massage the area to warm it up. B. Discontinue the therapy and assess the client. C. Notify the health care provider of the findings. D. Document the findings in the client's medical record.
B. Discontinue the therapy and assess the client.
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. Pasta salad B. Fish C. Banana D. Green beans
B. Fish
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 I B. Stage II C. Stage III D. Stage IV
B. Stage II
A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action? A. Reassure the client that this is a normal effect of a sitz bath and monitor the client closely. B. Stop the sitz bath, call for help, and help the client to the toilet to sit down. C. Stop the sitz bath and help the client ambulate back to the client room. D. Call a code blue because the client may be experiencing a myocardial infarction.
B. Stop the sitz bath, call for help, and help the client to the toilet to sit down.
The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood? A. transparent B. gauze C. hydrocolloid D. adhesive strips with eyelets
B. gauze
The wound care nurse is performing assessment of clients. Which wound complications does the nurse report to the health care provider? Select all that apply. A. a wound with approximated edges 3 days after a surgical procedure B. partial disruption of wound layers C. viscera protruding through the incisional area D. a wound with a pink wound bed and no drainage present E. a wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5 F. fistula formation
B. partial disruption of wound layers C. viscera protruding through the incisional area E. a wound with an increase in the flow of serosanguineous fluid F. between postoperative days 4 and 5 F. fistula formation
The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care? A. cleansing the labia with scented soap B. soaking in a warm bath for drainage C. applying an ice pack to relieve pain D. exposing the area to a heat lamp
B. soaking in a warm bath for drainage
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. use pillows to maintain a side-lying position as needed C. provide incontinent care every 4 hours as needed D. place a foot board on the bed
B. use pillows to maintain a side-lying position as needed
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 should keep this on my ankle until it is numb." B. "I must wait 15 minutes between applications of cold therapy." 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."
A nurse is caring for clients on a medical-surgical unit. On the basis of known risk factors, the nurse understands that which client has the highest risk for developing a pressure injury? A. 35-year-old client who was admitted after a motor vehicle accident, is on a liquid diet, and has bilateral casts on the upper extremities B. 45-year-old client who has cancer, is receiving chemotherapy, is incontinent, and is being admitted with leukopenia C. 65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest D. 70-year-old client with Alzheimer disease who wanders the nursing unit using a walker and refuses to sit and eat meals
C. 65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest
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. Hemoglobin A1C 5% B. Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L) C. Albumin 2.8 mg/dL (28.0 g/L) D. White blood cell count 14,800 mm3 (14.8 x 109/L)
C. Albumin 2.8 mg/dL (28.0 g/L)
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 in a circular pattern, beginning on the perimeter of the wound. C. Clean the wound from the top to the bottom and from the center to outside. D. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.
C. Clean the wound from the top to the bottom and from the center to outside.
The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? A. Contact the health care provider. B. Change the dressing. C. Document the findings. D. Notify the wound care nurse.
C. Document the findings.
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. Epidermis B. Dermis C. Subcutaneous tissue D. Muscle layer
C. Subcutaneous tissue
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 the skin and tissue with some type of instrument; tissue not aligned B. Cutting with a sharp instrument with wound edges in close approximation with correct alignment C. Tearing of a structure from its normal position D. Puncture of the skin
C. Tearing of a structure from its normal position
The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? A. assessing for the use of antihypertensives B. assessing the client for claustrophobia C. assessing the wound for active bleeding D. assessing the client's mental status
C. assessing the wound for active bleeding
A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: A. infection. B. herniation. C. dehiscence. D. evisceration.
C. dehiscence.
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. primary intention B. maturation C. secondary intention D. tertiary intention
C. secondary intention
A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? A. serous B. purulent C. serosanguineous D. sanguineous
C. serosanguineous
A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? A. primary intention B. secondary intention C. tertiary intention D. quadratic intention
C. tertiary 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. bandage B. gauze C. transparent D. hydrocolloid
C. transparent
The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? A. gauze B. adhesive strips with eyelets C. transparent D, hydrocolloid
C. transparent
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. "I will not remove the staples myself." C. "After delivery, I will have sutures in place." D. "Reinforced adhesive skin closures will hold my wound together until it heals."
D. "Reinforced adhesive skin closures will hold my wound together until it heals."
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? A. "This is normal tissue." B. "That is old clotted blood underneath the wound" C. "That is called undermining, a type of tissue erosion." D. "That is necrotic tissue, which must be removed to promote healing."
D. "That is necrotic tissue, which must be removed to promote healing."
The nurse is teaching a client about healing of a minor surgical wound by the first intention. What teaching will the nurse include? A. "The margins of your wound are not in direct contact." B. "This is a complex reparative process." 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 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. Stroke the culture swab on surrounding skin first. C. Utilize the culture swab to obtain cultures from multiple sites. D. Keep the swab and the inside of the culture tube sterile.
D. Keep the swab and the inside of the culture tube sterile.
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. Arteries and veins must be patent and functioning well. B. The volume of circulating blood must be sufficient. C. The heart must be able to pump adequately. D. Local capillary pressure must be lower than external pressure.
D. Local capillary pressure must be lower than external pressure.
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. Staging the wound for assessment D. The status of the client's tetanus immunization
D. The status of the client's tetanus immunization
A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk? A. a client 45 years of age who has paraplegia B. a client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history C. a client 75 years of age who uses a cane and has dementia D. a client 68 years of age who is bedfast related to severe head trauma
D. a client 68 years of age who is bedfast related to severe head trauma
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
A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? A. puncture B. laceration C. contusion D. avulsion
D. avulsion
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. dehiscence C. hemorrhage D. evisceration
D. evisceration
When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk? A. friction B. necrosis of tissue C. ischemia D. shearing force
D. shearing force
