NUR 120 Taylor Chapter 31 - Skin Integrity and Wound Care

The 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? "Plan to begin douching routinely immediately after your procedure." "The Pap procedure includes application of a douche." "Douching is recommended so that you are clean for the examination." "Do not douche 24-48 hours before the procedure."

"Do not douche 24-48 hours before the procedure." Clients should be informed to refrain from douching 24-48 hours prior to a Pap test, as this can wash away diagnostic cells. The healthcare provider is unlikely to recommend routine douching; this procedure is usually used to assist with treatment of an infection. The Pap procedure involves obtaining cell samples; it does not include application of a douche.

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." "I should keep this on my ankle until it is numb." "I can let this stay on my ankle an hour at a time." "I must wait 15 minutes between applications of cold therapy."

"I will put a layer of cloth between my skin and the ice pack." Teaching has been affective 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 skin becomes mottled or numb, as 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 reapplying.

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

"I will squeeze the chamber and apply the cap to maintain negative pressure." The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless it is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain uses gauze at the end of the drain to catch drainage.

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include? "Steri-Strips can be peeled off after 48 hours." "You only need a binder to hold your incision together." "It is important to keep your sutured incision clean." "You will have staples in place for several weeks."

"It is important to keep your sutured incision clean." After a Cesarean section, a client will be sutured and have staples put in place for a number of days. It is important to keep the sutured incision clean. Steri-Strips are not strong enough to hold this type of wound together. A binder is not sufficient to hold this type of incision together.

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching? "I may have staples in place for a number of days." "Steri-Strips will hold my wound together until it heals." "I will not remove the staples myself." "After delivery, I will have sutures in place."

"Steri-Strips will hold my wound together until it heals." After a Cesarean section, a client will be sutured and have staples put in place for a number of days. The healthcare provider or nurse will remove staples. Steri-Strips are not strong enough to hold this type of wound together.

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

"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 where margins of the wound are not in direct contact. Third-intention healing takes place when wound edges are intentionally left widely separated and are later brought together for closure.

The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate? "You may be correct. I will check with your primary health care provider." "Wounds heal better when a moist wound bed is maintained." "Allowing a scab to form would prevent us from observing the wound for signs of infection." "This wound is too large for a scab to form over it, so a moist dressing is the best alternative."

"Wounds heal better when a moist wound bed is maintained." A moist wound surface enhances the cellular migration necessary for tissue repair and healing.

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

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.

The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? Assess for the use of antihypertensives. Assess the client for claustrophobia. Assess the wound for active bleeding. Assess the client's mental status.

Assess the wound for active bleeding. Negative-pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed. NPWT is not considered for the use in the presence of active bleeding. The nurse needs to assess for the use of anticoagulants, not antihypertensives, because these can cause bleeding. Mental status and the presence of claustrophobia are not significant when initiating negative-pressure wound therapy.

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? Clean the wound from the bottom to the top, and outside to center. Once the wound is cleaned, dry the area with an absorbent cloth. Clean the wound from the top to the bottom, and center to outside. Use clean technique to clean the wound.

Clean the wound from the top to the bottom, and 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 in the same manner and apply ointment and dressing.

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

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 client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to? Depression Urinary incontinence Bowel obstruction Decubitus ulcer

Decubitus ulcer Many factors predispose an individual to have pressure ulcers; factors can be physical (local infections, malnutrition), functional (impaired mobility, incontinence), and psychosocial (poor adherence to treatment, impaired cognition).

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? Infection of the wound Herniation of the wound Evisceration of the viscera Dehiscence of the wound

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.

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 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 Evisceration Necrosis Maceration

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 assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication? Fistula Dehiscence Hemorrhage Evisceration

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.

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse to select to promote wound healing? Banana Pasta salad Green beans Fish

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.

The nurse is caring for a client in the emergency department who cut herself 15 minutes ago while preparing dinner at her home. The nurse understands the client's wound is in which phase of wound healing? Hemostasis phase Inflammatory phase Maturation phase Proliferation phase

Hemostasis phase Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin with other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and to release growth factors. The proliferation phase is the regenerative phase in which granulation tissue is formed. The maturation phase involves collagen remodeling.

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 of the following actions should the nurse perform in obtaining a wound culture? Utilize the culture swab to obtain cultures from multiple sites. Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Keep the swab and inside of the culture tube sterile.

Keep the swab and 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 surround the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

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

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

The nurse is instructing mothers of toddlers on the care of skin and the prevention of injury. The nurse should include which of the following educational interventions? Provide time for interaction with other children to assist with socialization. Read to the child daily to enhance intellectual development. Be sure the child receives 3 servings of dairy products daily. Protect from burns by covering electric outlets, and have a safe zone.

Protect from burns by covering electric outlets, and have a safe zone. Toddlers and preschoolers are susceptible to burns. Instructions should include keeping hot liquids out of their reach and capping electrical outlets with protective covers.

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 types should the nurse document? Serous Sanguineous Serosanguineous Purulent

Serosanguineous Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. 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 woman with a labile carbuncle. Which intervention will most likely be included in the plan of care? Cleanse labia with scented soap. Apply an ice pack to relieve pain. Soak in a warm bath for drainage. Expose the area to a heat lamp.

Soak in a warm bath for drainage. = Heat promotes vasodilation, allowing for the consolidation of pus in infected areas. Scented products may contain chemicals that promote irritation to the infected area and have no curative benefits to this particular client. Cold application will result in vasoconstriction and will not promote healing.

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? Stage II Stage I Stage IV Stage III

Stage III Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscles.

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? Epidermis Dermis Subcutaneous tissue Muscle layer

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

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 edged in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

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? Transparent Bandage Gauze Hydrocolloid

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 wounds moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

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

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.

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 ulcer? Provide incontinent care every 4 hours as needed. Use pillows to maintain a side-lying position as needed. Elevate the head of the bed 90 degrees. Place a foot board on the bed.

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 to the skin. A foot board prevents footdrop in clients but does not decrease the risk for pressure ulcers.

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? "You will likely experience periods of increased skin outbreaks and periods of remissions." "The condition is hard to cure." "You will have this disease for life." "Your personal health habits will dictate how well you handle this condition."

You will likely experience periods of increased skin outbreaks and periods of remissions." Psoriasis is a chronic condition. It may be managed with lifestyle changes and medications. There is no permanent cure. Periods of remission are followed by exacerbations, which can be triggered by stress, infection, or environmental factors.

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 a small plastic ruler a sterile tongue blade lubricated with water soluble gel an otic curette

a sterile, flexible applicator moistened with saline A sterile, flexible applicator is the safest implement to use. The other implements are too large, inflexible, or not sterile.

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

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.

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 gauze dressing premedicated with antibiotics a gauze dressing precut halfway to fit around the IV line a transparent film a dressing with a nonadherent coating

a transparent film Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings do not allow the nurse to visualize the site without partially or completely removing the dressing.

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? puncture avulsion contusion incision

contusion A contusion is an injury to soft tissue, so this is what the nurse expects to see based on the incident. A puncture involves an opening of 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 stripped surface layers of skin. An avulsion has stripped away of large areas of skin and underlying tissues.

The nurse has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn? OpSite Montgomery strap Tegasorb gauze

gauze Gauze dressings absorb blood or drainage. Montgomery straps are strips of tape with eyelets which are used to secure a gauze dressing that needs frequent changing; they are not necessary for this type of wound. Transparent dressings like OpSite are used to protect intravenous insertion sites. Hydrocolloid dressings like Tegasorb are used to used keep a wound moist.

A skin infection caused by beta-hemolytic streptococci common in children is: herpes. acne vulgaris. scabies. impetigo.

impetigo. Impetigo, which usually is caused by beta-hemolytic streptococci, is the most common bacterial

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? avulsion laceration incision abrasion

incision An incision involves a clean separation of skin and tissue with smooth, even edges. Therefore, the nurse documents the finding as an incision. An avulsion has stripped away of large areas of skin and underlying tissues. An abrasion involves stripped surface layers of skin. A laceration involves separation of skin and tissue with torn, irregular edges. Therefore, the nurse does not document the finding as an avulsion, abrasion, or laceration.

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate? infection dehiscence fistula evisceration

infection Symptoms of infection usually become apparent within 2 to 7 days after an injury or surgery; often the client is at home. Symptoms include purulent drainage; increased drainage; pain, redness, and swelling around the wound; increased body temperature; and increased WBCs.

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: primary intention. secondary intention. tertiary intention. dehiscence.

primary intention. Wounds healing by primary intention form a clean, straight line with little loss of tissue. Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue. Wounds healing by delayed primary intention or tertiary intention are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed. Dehiscence is wound separation, not wound healing.

The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot, and injured the worker's foot. What type of injury does the nurse anticipate? contusion avulsion incision puncture

puncture A puncture involves an opening of skin caused by a narrow, sharp, pointed object such as a nail. Therefore, the nurse documents this finding as a puncture. An incision involves a clean separation of skin and tissue with smooth, even edges. An avulsion has stripped away of large areas of skin and underlying tissues. An abrasion involves stripped surface layers of skin. A contusion is an injury to soft tissue. Therefore, the nurse does not document the finding as an incision, avulsion, or contusion.

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 excess drainage and wet tissue to prevent maceration of surrounding skin removing dead or infected tissue to promote wound healing removing purulent drainage from the wound bed in order to accurately assess it stimulating the wound bed to promote the growth of granulation tissue

removing dead or infected tissue to promote wound healing Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

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: third degree second degree fourth degree first degree

second degree 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.

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? ischemia friction shearing force necrosis of tissue

shearing force A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn? usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown superficial, may be pinkish or red with no blistering may vary from brown or black to cherry red or pearly white; bullae may be present also called a superficial partial-thickness burn, can appear dry and leathery

usually moist with blisters, they 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.

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

"Do you experience incontinence?" The client's health history is an essential component for 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 ulcers. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about skin care regimens, such as the use of lotions, but this would not be the priority in determining the risk for pressure ulcer development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure ulcer development.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage? Serosanguineous Purulent Sanguineous Serous

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

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 is 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.

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

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.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. Pick the crusts off the sutures with the forceps before removing them. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Do not attempt to remove the sutures because they need more time to heal.

Moisten sterile gauze with sterile saline to 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 sutures.

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? Perform the dressing change when the client is fatigued after physical therapy. Plan to administer a prescribed analgesic immediately prior to the dressing change. Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. Perform the dressing change during mealtime to allow for distraction.

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.

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? Stage IV Stage II Stage I Stage III

Stage II A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater. A stage I pressure ulcer 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 ulcer 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. Ulcers at this stage may include undermining and tunneling. Stage IV ulcers 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.

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces? a client who must remain on his back for long periods of time a client who lies on wrinkled sheets a client sitting in a chair who slides down a client who lifts himself up on his elbows

a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

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

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.