Nursing Exam 4-Chapter 32 Qustions
A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options. 1 Clean the incision using the wound cleanser and gauze. 2 Apply adhesive closure strips. 3 Remove every other suture to be sure the wound edges are healed. 4 Grasp the knot with the forceps and pull the cut suture through the skin. 5 Using the scissors, cut one side of the suture below the knot, close to the skin. 6 Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin.
1, 6, 5, 4, 3, 2
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. 1 Inflammatory 2 Hemostasis 3 Maturation 4 Proliferation
2, 1, 4, 3
A nurse is providing wound care for a client who has a pressure inury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options. 1 Use nonsterile gloves. 2 Cleanse the wound with normal saline. 3 Remove old dressing. 4 Apply sterile gloves. 5 Apply wound covering. 6 Give pain medication.
6, 1, 3, 4, 2, 5
A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action? a. Stop the sitz bath, call for help, and help the client to the toilet to sit down. b. Reassure the client that this is a normal effect of a sitz bath and monitor the client closely. c. Call a code blue because the client may be experiencing a myocardial infarction. d. Stop the sitz bath and help the client ambulate back to the client room.
a
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. Use clean technique instead of sterile technique if the wound is closed. b. Apply petroleum jelly to the periwound skin to protect it from the irrigation solution. c. If new bleeding is noted, continue irrigation cautiously and then notify the health care provider. d. Stop irrigating when the solution from the wound turns light pink.
a
A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother: a. to apply sunscreen when exposed to ultraviolet rays. b. that lanugo is hair of a different color that is permanent. c. to never trim the baby's nails due to susceptibility to infection. d. to only use cloth diapers, since disposable ones can cause eczema.
a
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. serosanguineous b. serous c. purulent d. sanguineous
a
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. use pillows to maintain a side-lying position as needed b. place a foot board on the bed c. elevate the head of the bed 90 degrees d. provide incontinent care every 4 hours as needed
a
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? a. mechanical debridement b. biosurgical debridement c. enzymatic debridement d. autolytic debridement
a
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. Black classification b. Red classification c. Yellow classification d. Unstageable
a
A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? a. biosurgical debridement b. enzymatic debridement c. mechanical debridement d. autolytic debridement
a
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. Puncture of the skin c. Cutting with a sharp instrument with wound edges in close approximation with correct alignment d. Tearing of the skin and tissue with some type of instrument; tissue not aligned
a
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 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. transparent b. bandage c. hydrocolloid d. gauze
a
A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b. Draw the shape of the wound and describe how deep it appears in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.
a
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? a. "I will squeeze the chamber and apply the cap to maintain negative pressure." b. "I will alternate between positive and negative pressure every 2 hours." c. "I will check and empty the drain every 6 hours." d. "I will apply a dressing at the end of the drain to catch any drainage."
a
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. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. 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. Do not attempt to remove the sutures because the wound needs more time to heal.
a
A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? a. The wound is 3 × 5 cm, with yellow tissue covering the entire wound. b. The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. c. The wound is a 3 × 5-cm blood-filled blister. d. The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing.
a
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 wound healing naturally that becomes infected. c. a large wound with considerable tissue loss allowed to heal naturally d. a wound left open for several days to allow edema to subside
a
The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing? a. hemostasis phase b. maturation phase c. proliferation phase d. inflammatory phase
a
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. Recompress the drain before replacing the cap. b. Don sterile gloves before manipulating the cap of the drain. c. Cleanse the area around the cap with alcohol for 30 seconds before removing it. d. Pin the drain to the client's gown after pulling the tubing taut.
a
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 keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. c. The nurse uses wet-to-dry dressings continuously. d. The nurse packs the wound cavity tightly with dressing material.
a
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 critical care client b. a client with cardiovascular disease c. an older client with arthritis d. a newborn
a
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? a. Document the findings and continue to monitor the patient. b. Administer antipyretics, as prescribed. c. Increase the frequency of assessment to every hour and notify the patient's primary care provider. d. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.
a
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
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 must remain on his back for long periods of time c. a client who lies on wrinkled sheets d. a client who lifts himself up on his elbows
a 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 injury from shearing forces would be a client sitting in a chair who slides down. pg.1055
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. a. Insert a swab into the wound. b. Press and rotate the swab several times over the wound surfaces. c. Place the swab in the culture tube when done. d. Tap the outside of the culture tube with the swab before placing it in the tube. e. Use the same swab for both wound sites. f. Touch the swab to the intact skin at the wound edges.
a, b, c
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. a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f. Serosanguineous drainage can be dark yellow or green depending on the causative organism.
a, b, c, d
A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For which type(s) of injury would the nurse be alert? Select all that apply. a. Concussion b. Broken left ankle c. Abrasions d. Bruising e. Soft tissue damage
a, b, c, d, e
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. "Your wound edges are right next to each other." c. "Your wound will be purposely left open for a time." d. "This is a simple reparative process." e. "The margins of your wound are widely separated."
a, b, d
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. a. No finger numbness or tingling b. Fingers with quick capillary refill c. Cyanosis d. Warm hand e. Decreased radial pulse
a, b, d The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers. Cyanosis, pallor, coolness, numbness, tingling, swelling, or absent or diminished pulse are signs that circulation may be decreased or that nerve function is impaired. pg.1046
The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. a. Slowly unclamp the tubing and allow the sitz bath to fill. b. Fill the bowl of the sitz bath about halfway full with tepid to warm water. c. Have the client soak for about 50 to 60 minutes. d. Insert tubing into the infusion port of the sitz bath. e. Hang the bag of tepid to warm water at the client's chest height on an IV pole. f. Ensure that the call bell is within reach.
a, b, d, f
The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least 1 in beyond the end of the new dressing if one is being applied. f. Clean to at least 3 in beyond the wound if a new dressing is not being applied.
a, b, e
A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply. a. encourage the client to take fluids every 2 hours b. pull the client up in bed as needed c. turn the client every 2 hours when the client is in bed d. provide incontinent care every 2 hours and as needed e. elevate the head of the bed 90 degrees four times daily
a, c, d
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. a. Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase. c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has generalized body response. f. A scar forms during the proliferation phase.
a, c, e
Which clients would be considered at risk for skin alterations? Select all that apply. a. a client receiving radiation therapy b. a client undergoing cardiac monitoring c. a client with diabetes d. a homosexual in a monogamous relationship e. a teenager with multiple body piercings
a, c, e
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. a. False b. True
b
A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? a. Tetanus, being able to walk, and scarring b. Tetanus, infection, wound care, and pain control c. Scarring, sutures, and wound care d. Prevention of recurring infection, ability to work, and wound care
b
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 status of the client's tetanus immunization c. The event leading up to the trauma d. Staging the wound for assessment
b
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 IV b. Stage II c. Stage I d. Stage III
b
A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? a. Keeps the wound clean b. Supports the area around the wound c. Maintains a moist environment d. Reduces swelling and inflammation
b
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? a. Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon b. Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement c. Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon d. Notify the surgeon STAT
b
A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? a. tertiary intention b. secondary intention c. primary intention d. desiccation
b
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
A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: a. a rash related to immobility. b. a rash related to a yeast infection. c. an allergic reaction to detergent. d. an allergic reaction to medications.
b
A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: a. infection. b. dehiscence. c. herniation. d. evisceration.
b
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: a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
b
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 surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." b. "Your wound will heal slowly as granulation tissue forms and fills the wound." c. "As soon as the infection clears, your surgeon will staple the wound closed." d. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."
b
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. evisceration c. hemorrhage d. dehiscence
b
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 e. Vitamin A
b
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. Document the findings in the client's medical record. b. Discontinue the therapy and assess the client. c. Notify the health care provider of the findings. d. Gently rub and massage the area to warm it up.
b
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? a. Irrigate the wound. b. Provide gentle cleansing of the wound. c. Debride the wound. d. Change the dressing frequently.
b
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. Necrosis b. Desiccation c. Maceration d. Evisceration
b
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. "Do you experience incontinence?" c. "Have you had any recent illnesses?" d. "How many meals a day do you eat?"
b
When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps? a. Apply skin barrier only on the right side of the wound over the irritation. b. Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. c. Apply skin barrier over the area of irritation to prevent further injury. d. Apply skin barrier only on the side of the wound without any irritation.
b
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. "That is old clotted blood underneath the wound" b. "That is necrotic tissue, which must be removed to promote healing." c. "That is called undermining, a type of tissue erosion." d. "This is normal tissue."
b "That is necrotic tissue, which must be removed to promote healing." Explanation: Wounds that are brown or black are necrotic and not considered normal. 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. pg.1071
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 a total separation of the wound with protrusion of the viscera through it." b. "Dehiscence is when a wound has partial or total separation of the wound layers." c. "Dehiscence is the softening of tissue due to excessive moisture." d. "Dehiscence is not anything that you need to worry about."
b Explanation: 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. pg.1053
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? a. "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." b. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." c. "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." d. "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."
b Explanation: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present. pg.1064
A client's risk for the development of a pressure injury is most likely due to which lab result? a. hemoglobin A1C 7% b. albumin 2.5 mg/dL c. glucose 110 mg/dL d. ``sodium 135 mEq/L
b 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. pg.1066
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. An infant's skin and mucous membranes are easily injured and at risk for infection. c. In children younger than 2 years, the skin is thicker and stronger than in adults. d. A child's skin becomes less resistant to injury and infection as the child grows.
b 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. pg.1045
A nurse is caring for a client who has recently undergone repair of a ventral hernia. What situations should the nurse assess for that may increase the risk for delay in surgical wound healing? Select all that apply. a. compromised peripheral circulation b. insufficient protein and vitamin C intake c. weak tissue and muscular support due to obesity d. distention of the abdomen from accumulated intestinal gas e. serous fluid accumulation preventing skin tissue approximation
b, c, d
A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply. a. reinserting the protruding structures and applying a pressure dressing b. placing the client in the low Fowler position c. covering the wound with a gauze moistened with normal saline d. using sterile technique e. packing the wound with iodoform gauze
b, c, d Evisceration of a wound is a medical emergency. The client should be placed in a low Fowler position and, with the use of sterile technique, the eviscerated structures should be covered with normal saline-moistened gauze. The surgeon should also be notified. The nurse should never reinsert protruding structures or apply a pressure dressing. This could cause the tissue to be injured. The wound should not be packed with iodoform gauze. The client will have surgery to replace the eviscerated structures. pg.1053
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. a. The patient takes time to think about responses to questions. b. The patient is 86 years old. c. The patient reports inability to control urine. d. The patient is scheduled for a hip arthroplasty. e. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). f. The patient reports increased pain in right hip when repositioning in bed or chair.
b, c, d, f
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? a. Administer the prescribed analgesic. b. Notify the health care provider of the pain. c. Assess the client's wound and vital signs. d. Document the pain and vital signs.
c
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. laceration b. puncture c. avulsion d. contusion
c
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? a. Placing the client in a side-lying position with a pillow between the lower legs b. Placing the client in the supine position with a pillow under the knees c. 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 d. Placing the client in a wheelchair with the back of the feet resting against the heel loops
c
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? a. "I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied."
c
A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.
c
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: a. to provide a sinus tract for drainage. b. to decrease dead space by decreasing drainage. c. to provide drainage for bile. d. to divert drainage to the peritoneal cavity.
c
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? a. Pain b. Impaired Skin Integrity c. Disturbed Body Image d. Disturbed Thought Processes
c
The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? a. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. b. Apply dry gauze to the wound and carefully apply saline to saturate it. c. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. d. Avoid using irrigation to clean the wound before changing the dressing.
c
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. first degree or superficial b. fourth degree or fat layer c. second degree or partial thickness d. third degree or full thickness
c
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
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. Green beans b. Banana c. Fish d. Pasta salad
c
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. exerting equal, but not excessive, tension with each turn of the bandage b. wrapping distally to proximally c. elevating and supporting the stump d. keeping the bandage free of gaps between turn
c
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? a. To turn the head away from the area whenever coughing b. To remain in bed for the next 4 hours c. To splint the area when engaging in activity d. To ambulate using a cane or walker
c
When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a. Using sterile technique, debride the wound. b. Place an antiembolism stocking on the client's leg. c. Off-load pressure from the heel. d. Contact the surgeon for debridement.
c
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? a. lubricating the area with skin oil b. pulling the client up from under the arms c. preventing the client from sliding in bed d. improving the client's hydration
c
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. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. b. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. c. Rotate the swab several times over the wound surface to obtain an adequate specimen. d. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station.
c Explanation: 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. pg.1112-1115
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. abrasion c. incision d. laceration
c Explanation: 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.pg.1048
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. a. Notify the health care provider of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. c. Place the patient in the low Fowler's position.
c, b, a
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. a. Enhanced healing due to the presence of sugars and proteins b. Delayed healing due to dead tissue present in the wound c. Decreased effectiveness of antibiotics against the bacteria d. Impaired skin integrity due to overhydration of the cells of the wound e. Delayed healing due to cells dehydrating and dying f. Decreased effectiveness of the patient's normal immune process
c, f
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? a. stimulating the wound bed to promote the growth of granulation tissue b. removing purulent drainage from the wound bed in order to accurately assess it c. removing excess drainage and wet tissue to prevent maceration of surrounding skin d. removing dead or infected tissue to promote wound healing
d
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? a. Clean the wound in a circular pattern, beginning on the perimeter of the wound. b. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. c. Use clean technique to clean the wound. d. Clean the wound from the top to the bottom and from the center to outside.
d
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? a. Keeping the head of the bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin
d
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? a. May vary from brown or black to cherry red or pearly white; bullae may be present b. Superficial, which may be pinkish or red with no blistering 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
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. Stop removing staples and apply an abdominal pad over the incision. b. Apply an occlusive pressure dressing after removing the staples. c. Apply adhesive wound closure strips after each staple is removed. d. Stop removing staples and inform the surgeon
d
A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a. Using sterile dressing supplies b. Suggesting dietary supplements c. Applying antibiotic ointment d. Performing careful hand hygiene
d
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. Herniation of the wound b. Evisceration of the viscera c. Infection of the wound d. Dehiscence of the wound
d
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. incision b. puncture c. avulsion d. contusion
d
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. Notify the wound care nurse. c. Change the dressing. d. Document the findings.
d
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. Utilize the culture swab to obtain cultures from multiple sites. b. Stroke the culture swab on surrounding skin first. c. Cleanse the wound after obtaining the wound culture. d. Keep the swab and the inside of the culture tube sterile.
d
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. "The surgeon will leave your wound open intentionally for a period of time." c. "The margins of your wound are not in direct contact." d. "Very little scar tissue will form."
d
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. "I will not remove the staples myself." d. "Reinforced adhesive skin closures will hold my wound together until it heals."
d
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 turn the head away from the area whenever coughing c. To ambulate using a cane or walker d. To splint the area when engaging in activity
d
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
Which best describes the proliferative phase, the third phase of the wound healing process? a. the onset of vasoconstriction, platelet aggregation, and clot formation b. marked by vasodilation and phagocytosis as the body works to clean the wound c. decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound d. reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization
d
Which is not considered a skin appendage? a. Eccrine sweat glands b. Sebaceous gland c. Hair d. Connective tissue
d
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. a gauze dressing precut halfway to fit around the IV line b. a dressing with a nonadherent coating c. a gauze dressing premedicated with antibiotics d. a transparent film
d Explanation: 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. pg.1072
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. large amounts of drainage that is clear and watery and has no smell b. copious drainage that is blood-tinged c. small amount of drainage that appears to be mostly fresh blood d. foul-smelling drainage that is grayish in color
d foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing. pg.1063