NUR 1050 Fundamentals II Chapter 32: Skin Integrity and Wound Care

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

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?

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

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?

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

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?

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

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity?

Clean perineal area daily but do not bathe full body on a daily basis

Which is not considered a skin appendage?

Connective tissue

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?

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?

Discontinue the therapy and assess the client.

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order.

Hemostasis Inflammatory Proliferation Maturation

When applying an external heating pad, which prescription from the health care provider would the nurse question?

Leave heating pad on for 45 minutes

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended?

Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down.

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?

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

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?

Performing careful hand hygiene

The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound?

Provide gentle cleansing of the wound.

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply.

Serous drainage is composed of the clear portion of the blood and serous membranes. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. Purulent drainage is composed of white blood cells, dead tissue, and bacteria.

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?

Subcutaneous tissue

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?

Transparent

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury?

Using a mild cleansing agent when cleansing the skin

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

A client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues?

applying the dressing with a binder

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

dehiscence.

The nurse is preparing a discharge plan for an older adult client who recently underwent a hernia repair. Which action should the nurse include in the care plan to assist with this client's recovery?

refer the client to a local group which provides home-delivered meals

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?

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?

use pillows to maintain a side-lying position as needed

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus

When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse?

Document the findings.

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.

Fingers with quick capillary refill Warm hand No finger numbness or tingling

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

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

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

cleanse with a new gauze for each stroke

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?

elevating and supporting the stump

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

hydrocolloid

What intervention(s) should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply.

proper client nutrition 2-hour turn schedule pressure redistribution support surfaces client repositioning with a lift

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

stage II

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is:

to provide drainage for bile.

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

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

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply.

Hemostasis occurs immediately after the initial injury. White blood cells move to the wound in the inflammatory phase. During the inflammatory phase, the patient has generalized body response.

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.

Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done.

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?

It is appropriate to use clean technique during this procedure.

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client?

Monitor intake and output.

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

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar.

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?

secondary intention

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?

stage IV

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage.

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

Supports the area around the wound

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 transparent film

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as:

Stage 2

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

corticosteroids

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

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?

"That is necrotic tissue, which must be removed to promote healing."

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."

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 Penrose drain promotes passive drainage into a dressing.

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?

As a stage I pressure injury

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?

Braden scale

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 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?

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?

Stage II

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?

Stop removing staples and inform the surgeon

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

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

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

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

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply.

Use standard precautions or transmission-based precautions when indicated. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. Clean to at least 1 in beyond the end of the new dressing if one is being applied.

A client's risk for the development of a pressure injury is most likely due to which lab result?

albumin 2.5 mg/dL

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?

evisceration

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 as an indication of infection?

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?

preventing the client from sliding in bed

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?

serosanguineous

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?

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

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Apply saline solution-moistened gauze over the protruding area.

Apply saline solution-moistened gauze over the protruding area.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

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?

Black classification

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last.

Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. Place the patient in the low Fowler's position. Notify the health care provider of the situation.

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?

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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?

Recompress the drain before replacing the cap.

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?

Tearing of a structure from its normal position

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply.

The patient is 86 years old. The patient reports inability to control urine. The patient is scheduled for a hip arthroplasty. The patient reports increased pain in right hip when repositioning in bed or chair.

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 critical care client

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply.

an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drug

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

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

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

mechanical debridement

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?

"I should see less swelling and redness with the cold treatment."

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?

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

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 nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

"Very little scar tissue will form."

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?

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

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

Apply a skin protectant to the skin around the incision.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

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

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply.

Decreased effectiveness of antibiotics against the bacteria Decreased effectiveness of the patient's normal immune process

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply.

Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications.

The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. Fill the bowl of the sitz bath about halfway full with tepid to warm water.

Insert tubing into the infusion port of the sitz bath. Slowly unclamp the tubing and allow the sitz bath to fill. Ensure that the call bell is within reach.

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

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?

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

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient?

The therapy provides a moist environment and stimulates blood flow to the wound.

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 is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

figure-of-eight turn

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?

incision

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

milia.

The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?

oblique

A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate?

Disturbed Body Image

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan?

Document the findings and continue to monitor the patient.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.