Prep U chapter 32: skin integrity and wound care

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"

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

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?

Tetanus, infection, wound care, and pain control

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 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 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?

implement a 2-hour repositioning schedule

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 pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

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 adges

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

the client has fistula formation