Prep U: Nutrition & Skin integrity and wound care

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 tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic.

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.

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.

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

Albumin 2.5 mg/dL, an albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury (range is 3.4 - 5.4 g/dL)

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, before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage.

A nurse provides discharge education for a client diagnosed with ketosis. Which nutrient would be added to this client's diet?

Carbohydrates

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

Dehiscence, dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever.

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.

A woman consumes pasta, grains, and other carbohydrates for which purpose?

Energy

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?

Every 4 to 6 hours explanation: Checking for residual before each feeding or every 4 to 6 hours during a continuous feeding according to institutional policy is implemented to identify delayed gastric emptying. Residuals are not measured immediately after a flush.

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, evisceration is the protrusion of viscera through an abdominal wound opening.

The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate?

Increase the client's fluid intake, dehydration can cause increases in hematocrit, BUN, and creatinine.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?

Serosanguineous, serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink or pink-yellow.

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 stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater.

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 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.

A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin?

Vitamin B12

The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?

Iodine

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.

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, healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

A home health care nurse is educating a client and caregivers on how to administer an enteral feeding. Which teaching points are appropriate? Select all that apply.

- Check for leaking of gastric contents around the insertion site (e.g., Is the guard too loose or balloon not filled adequately?). - Clean around the gastric tube with soap and water, making sure it is adequately rinsed. - Keep the head elevated while delivering a gastric feeding and for approximately 1 hour after the feeding. - Mark gastrostomy tubes with an indelible marker and check the mark to make sure it is at the level of the abdominal wall.

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.