Skin Integrity & Wound Care

The nurse prepares to irrigate the client's wound. The primary reason for this procedure is to: 1. Decrease scar formation 2. Remove debris from the wound 3. Improve circulation from the wound 4. Decrease irritation from wound drainage

ANS: 2 The gentle washing action of the irrigation cleanses a wound of exudate and debris. The primary purpose of wound irrigation is not to improve circulation, decrease scar formation, or decrease irritation from wound drainage, but to remove debris from the wound.

Upon inspection of the client's wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select based on the wound assessment is: 1. Foam 2. Hydrogel 3. Hydrocolloid 4. Transparent film

ANS: 1 A foam dressing absorbs exudate and debris while maintaining a moist environment. Topical agents, such as antibiotic ointment, may also be used with a foam dressing. This would be the most appropriate type of dressing for this wound. A hydrogel dressing provides moisture to a clean granular wound. A hydrocolloid dressing interacts with the wound fluid to provide a moist environment. Transparent film protects from friction injury and may be left in place up to 7 days.

A client presents with a pressure ulcer that the nurse is documenting in the medical record. The nurse notes necrotic tissue on the pressure ulcer, which indicates that: 1. The pressure ulcer is automatically a stage IV 2. The pressure ulcer cannot be staged 3. The client has been abused 4. The pressure ulcer is healing

ANS: 2 Staging systems for pressure ulcers are based on describing the depth of tissue destroyed. Accurate staging requires knowledge of the skin layers, and a major drawback of a staging system is that you cannot stage an ulcer covered with necrotic tissue because the necrotic tissue is covering the depth of the ulcer. The necrotic tissue must be debrided or removed to expose the wound base to allow for assessment. The necrotic tissue present on the pressure ulcer doesn't necessarily indicate that the client has been abused, nor does it indicate that the wound is healing.

The nurse notes that the 43-year-old male client has an abrasion on his upper right thigh that he received 2 days ago when he was involved in a bicycle accident. The abrasion is red, swollen, warm, and throbbing. The nurse knows that the wound shows signs of being: 1. Infected 2. In the inflammatory phase of healing 3. In the proliferative phase of healing 4. In the remodeling phase of healing

ANS: 2 The inflammation stage is the body's reaction to wounding and begins within minutes of injury and lasts approximately 3 days. The inflammatory response is beneficial, and there is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a closed compartment. Some contaminated or traumatic wounds show signs of infection early, within 2 to 3 days. The client has a fever, tenderness and pain at the wound site, and an elevated white blood cell count. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism. With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization. Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound.

The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

ANS: 2 This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? (Select all the apply.) 1. Presence of pain 2. Depth of damage 3. Length and width 4. Presence of drainage 5. Description of drainage 6. Condition of surrounding tissue

ANS: 2, 3, 4, 5, 6 Assessment includes depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin. Presence of pain is not a component of this charting.

When asked what the role of the skin is in maintaining homeostasis, the answer that reflects the greatest insight is: 1. "Our body needs vitamin D, and without healthy skin we cannot utilize it into a form we can use." 2. "Without skin we would not be able to enjoy the sense of touch that is so important to us as humans." 3. "The skin is a barrier that is really quite good at keeping disease-causing pathogens from getting into our body." 4. "It is the pain with its pain receptors that alert us to danger so that we can take appropriate action in order to be safe."

ANS: 3 Although it is a sensory organ for pain, temperature, and touch and synthesizes vitamin D, its primary role is that of a protective barrier against disease-causing organisms.

The nurse is aware that application of cold is indicated for the client with: 1. Menstrual cramping 2. An infected wound 3. A fractured ankle 4. Degenerative joint disease

ANS: 3 Direct trauma such as fractures or sprains may be treated with cold. The application of cold can initially diminish swelling and pain. Application of heat to reduce muscle tension and reduce pain would be more appropriate for the client with menstrual cramping. The application of cold is not indicated for the client with an infected wound because it reduces the blood flow to the area. This would limit the number of macrophages to clear the area of bacteria and would lessen the nutrient supply to the already impaired tissue. The effects of heat application would be more beneficial to the client with degenerative joint disease.

A client has a healing abdominal wound. The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing? 1. Primary intention 2. Inflammatory phase 3. Proliferative phase 4. Secondary intention

ANS: 3 During the proliferative phase, the wound fills with granulation tissue (including collagen formation), the wound contracts, and the wound is resurfaced by epithelialization. Primary intention is not a phase of wound healing. Wounds that heal by primary intention have minimal tissue loss, such as a surgical wound. The edges are approximated and the risk for infection is low. During the inflammatory phase, platelets gather to stop bleeding, a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris. Secondary intention is not a phase of wound healing. Wounds that heal by secondary intention have loss of tissue, such as a pressure ulcer. The wound is left open until it becomes filled by scar tissue.

To reduce pressure points that may lead to pressure ulcers, the nurse should: 1. Position the client directly on the trochanter when side-lying 2. Use a donut device for the client when sitting up 3. Elevate the head of the bed as little as possible 4. Massage over the bony prominences

ANS: 3 Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. The client should not be positioned directly on the trochanter because this can create pressure over the bony prominence. Donut-shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia. Bony prominences should not be massaged. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk for injury to underlying tissue and pressure ulcer formation.

The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the client who has exposure to: 1. Urine 2. Purulent exudates 3. Pancreatic fluids 4. Serosanguineous drainage

ANS: 3 Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Exposure to urine, bile, stool, acetic fluid, and purulent wound exudates carries a moderate risk for skin breakdown. Serosanguineous drainage is not caustic to the skin, and the risk for skin breakdown from exposure to this fluid is low.

The nurse is assessing the pressure ulcer of a 68-year-old female client. Which of the following would indicate to the nurse that healing is taking place? 1. Eschar 2. Slough 3. Granulation tissue 4. Exudate

ANS: 3 Granulation tissue is red moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Black or brown necrotic tissue is eschar which you will need to remove before healing can proceed. Soft, yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and you will need to remove this before the wound is able to heal. Wound exudate describes the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. Excessive exudate indicates the presence of infection. The presence of exudate on the skin surrounding the wound is indicative of wound deterioration.

Granulated tissue is best described as: 1. Soft, yellow, and stringy 2. Black, hard, and necrotic 3. Red, moist, and vascular-rich 4. Yellow, spongy, and sinewy

ANS: 3 Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft, yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and you will need to remove this before the wound is able to heal. Black or brown necrotic tissue is eschar, which you will also need to remove before healing can proceed.

Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client? 1. "2-cm area of scaly, dry skin located on the client's right heel." 2. "2-cm area of nonblanching erythema located on the client's right heel." 3. "2-cm area purplish blue in color surrounded by lighter-colored skin located on right heel." 4. "2-cm area of blanching erythema located on the client's right heel; entire foot warm to the touch."

ANS: 3 In dark-skinned individuals areas of pressure appear darker than surrounding skin and have a purplish/bluish hue; the temperature of the area may be warm or cool to the touch. The remaining options use descriptives not applicable to the dark-skinned individual or less definite indicators.

Which of the following statements made by the nurse shows the greatest insight into the need to manage the risk factors that contribute to the formation of a pressure ulcer? 1. "Her diet needs to include more protein and less sugary foods." 2. "She needs to be moved more gently and with attention to her skin." 3. "We need to decrease the time she spends with the weight of her body resting on her hip 4. "The urinary incontinency makes the risk for developing a pressure ulcer so much greater for her."

ANS: 3 Pressure is the major cause in pressure ulcer formation. Three pressure-related factors contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance. The remaining options, although related to contributing factors, do not address the primary factor, pressure.

Although all of the following represent poor transfer techniques, which is most likely to result in a shearing injury to the skin of an older adult client? 1. Only one staff member positioning an immobile client 2. Allowing the heels to be dragged as the client is being positioned 3. Failing to lower the head of the bed before moving the client upward 4. Neglecting to use a lift sheet when moving the client to the head of the bed

ANS: 3 Shear is the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. The remaining options result in friction damage to the client's skin.

The nursing student is bathing a 73-year-old Native American female client. The student reports to the nurse that the client has what looks like cyanosis on her sacrum. The nurse goes with the student to assess the client but suspects that the cyanosis that the student sees is most likely: 1. Caused from the client laying on her back most of the morning 2. Caused by the bright sunlight in the room 3. Normal hyperpigmentation of mongolian spots 4. Blue dye that has bled off the cheap new gowns that the hospital has purchased

ANS: 3 The nurse should not confuse the normal hyperpigmentation of mongolian spots that are seen on the sacrum of African, Native American, and Asian clients as cyanosis. Observe the client's skin in nonglare daylight. The Gaskin's Nursing Assessment of Skin Color (GNASC) is a useful tool for assessment for identifying changes in skin color that increase the client's risk for pressure ulcers.

When cleaning a wound, the nurse should: 1. Wash over the wound twice and discard that swab 2. Move from the outer region of the wound toward the center 3. Start at the drainage site and move outward with circular motions 4. Use an antiseptic solution followed by a normal saline rinse

ANS: 3 To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in circular rotations outward from a point closest to the drain. The nurse never uses the same piece of gauze or swab to cleanse across an incision or wound twice. The wound should be cleansed in a direction from the least contaminated area, such as from the wound to the surrounding skin. The wound is cleaned from the center region to the outer region. An antiseptic solution is not used to clean a wound, as it may be cytotoxic.

A client on the medical unit is taking steroids and also has a wound from a minor injury. To promote wound healing for this client, the nurse recommends that which of the following be specifically added? 1. Iron 2. Folic acid 3. Vitamin A 4. B complex vitamins

ANS: 3 Vitamin A can reverse steroid effects on skin and delayed healing. Iron does not reverse the effects of steroids. It is important in the transport of oxygen. Folic acid does not reverse the effects of steroids. It is a B complex vitamin needed for DNA synthesis. The B complex vitamins do not reverse the effects of steroids. The B vitamins affect growth and stimulate appetite, lactation, and the gastrointestinal, neurological, and endocrine systems.

In reviewing the client's nutritional intake, the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity. The nurse suggests that the client eat: 1. Fish 2. Eggs 3. Liver 4. Citrus fruits

ANS: 4 Citrus fruits contain vitamin C, which is important in collagen synthesis, capillary wall integrity, and fibroblast function. Fish and eggs contain protein and vitamin E. Protein plays a role in neogenesis, collagen formation, and wound remodeling. Liver contains vitamin A, which is important in epithelialization and wound closure.

Which of the following statements made by the nurse shows the most thorough understanding of the therapeutic value of testing a reddened area on the heel of a mobility-impaired client for blanching? 1. "If it blanches, the problem isn't too bad." 2. "When it stays red, the damage is great." 3. "Nonblanching hyperemia is a poor indictor of healing." 4. "Blanching denotes an attempt to deliver blood to the site."

ANS: 4 If the area blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanching hyperemia. If, however, the erythemic area does not blanch (nonblanching erythema) when you apply pressure, deep tissue damage is probable.

Pressure ulcers form primarily as a result of: 1. Nitrogen buildup in the underlying tissues 2. Prolonged illness or disease 3. Tissue ischemia 4. Poor nutrition

ANS: 3 Pressure is the major cause of pressure ulcer formation. Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. Prolonged illness or disease and poor nutrition may place a client at risk for pressure ulcer development.

Wounds that heal by primary intention will most likely: 1. Have minimal scarring 2. Contain infected tissue 3. Present with ragged edges 4. Have portions of missing tissue

ANS: 1 Healing occurs by epithelialization; these wounds heal quickly with minimal scar formation.

The nurse uses the Norton scale in the extended care facility to determine the client's risk for pressure ulcer development. Which one of the following scores, based on this scale, places the client at the highest level of risk? 1. 6 2. 8 3. 15 4. 19

ANS: 1 According to the Norton scale, a lower score indicates a higher risk for pressure ulcer development. The total score ranges from 5 to 20. The client at highest risk would be the client with a score of 6.

The inflammatory stage of healing is characterized by: 1. Throbbing pain 2. Granulation tissue 3. Wound contraction 4. Collagen scarring

ANS: 1 Localized redness, edema, warmth, and throbbing pain are characteristics of the inflammatory stage of healing.

The initial nursing intervention for the assessment of external hemorrhaging is: 1. Close monitoring of the wound dressing for bloody drainage 2. Frequent assessment of the client's blood pressure 3. Monitoring of the client's heart rate 4. Redressing of the wound

ANS: 1 The nurse observes dressings covering the wound for bloody drainage.

Which of the following clients is most at risk for developing a pressure ulcer? 1. 3-year-old in Buck's traction 2. 33-year-old comatose client 3. 76-year-old client who has had a mild stroke 4. 38-week-old infant in an oxygen hood

ANS: 2 Clients in a coma cannot perceive pressure and are unable to move voluntarily to relieve pressure.

Wounds that are contaminated or infected heal by: 1. Secondary intention 2. Tertiary intention 3. Primary intention 4. Open intention

ANS: 2 Wounds that are contaminated and require observation for signs of inflammation are left open for several days. When wound edges are approximated; this is tertiary intention healing.

When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? 1. Clean the area with mild soap, dry, and add a protective moisturizer. 2. Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area. 3. Soak the area in normal saline solution. 4. Wash the area with an astringent and paint it with povidone-iodine (Betadine).

ANS: 1 The skin should be cleansed and completely dried and a protective moisturizer applied to keep the epidermis well lubricated. Hydrogen peroxide is cytotoxic and should not be used. A heat lamp is not necessary and would increase the client's risk for an accidental burn. The area should not be soaked because this may lead to maceration of the skin. The area should not be cleansed with an astringent and painted with povidone-iodine. An astringent may cause excessive drying of the tissue, and povidone-iodine is cytotoxic.

A client comes to the emergency department following an injury. The nurse implements appropriate first aid for the client when: 1. Removing any penetrating objects 2. Elevating an affected part that is bleeding 3. Vigorously cleaning areas of abrasion or laceration 4. Keeping any puncture wounds from bleeding

ANS: 2 If a client is bleeding, the nurse applies direct pressure and elevates the affected part. When a penetrating object is present, it is not removed. Removal could cause massive, uncontrolled bleeding. Vigorous cleaning can cause bleeding or further injury. Abrasions and minor lacerations should be rinsed with normal saline and lightly covered with a dressing. Puncture wounds are allowed to bleed to remove dirt and other contaminants.

Which of the following statements shows the greatest understanding of wound staging? 1. "An ulcer must involve broken skin in order to be staged." 2. "A wound that contains slough is difficult to stage." 3. "This wound can't be staged until it's debrided." 4. "The health care provider will need to stage the ulcer."

ANS: 3 An unstageable ulcer is a full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore the stage cannot be determined. The remaining options are not correct.

A cognitively impaired client spends hours a day involuntarily wringing her hands. Which of the following interventions is the most therapeutic as a means of minimizing this client's risk for friction damage to her hands? 1. Placing thin cotton mitts on her hands 2. Frequently distracting her with conversation 3. Regularly reminding her to stop wringing her hands 4. Getting a prescription to minimize the compulsive behavior

ANS: 1 A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The remaining options are not as likely to be effective with a cognitively impaired client.

The client has a stage IV pressure ulcer. In accordance with the Agency for Healthcare Research and Quality (AHRQ), the nurse recommends that the client should have a(n): 1. Foam mattress 2. Air-fluidized bed 3. Rotokinetic bed 4. Static support surface

ANS: 2 Air-fluidized beds are recommended for clients with burns or multiple stage III or stage IV pressure ulcers. A foam mattress is recommended for pressure reduction in clients at high risk for developing a pressure ulcer. A Rotokinetic bed is recommended for clients who are at risk for or have developed atelectasis and/or pneumonia. A static support surface is not recommended for a client with a stage IV ulcer. It is used for clients at high risk for developing a pressure ulcer.

Which of the following clients has the greatest risk for friction-induced skin breakdown? 1. A client who is obese and is frequently incontinent of both urine and feces 2. A client who insists she is comfortable only when positioned on her left side 3. A client who is cognitively impaired and comforts herself by wringing her hands 4. An immobile client who slides down in the recliner where he spends the morning hours

ANS: 3 A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The other options represent friction or moisture factors that contribute to skin breakdown.

The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is: 1. A reduced skin elasticity is common in the older adult 2. The attachment between the epidermis and dermis is weaker 3. The older client has less subcutaneous padding on the elbows 4. Older adults have a poor diet that increases risk for pressure ulcers

ANS: 3 Although all the options are related to causes of skin injury in older adults, the hypodermis decreases in size with age, and so the older client has little subcutaneous padding over bony prominences; thus they are more prone to skin breakdown.

The nurse is planning a program on wound healing and includes information that smoking influences healing by: 1. Suppressing protein synthesis 2. Creating increased tissue fragility 3. Depressing bone marrow function 4. Reducing functional hemoglobin in the blood

ANS: 4 Smoking reduces the amount of functional hemoglobin in the blood, thus decreasing tissue oxygenation. Antiinflammatory drugs suppress protein synthesis. Radiation creates tissue fragility. Chemotherapeutic drugs can depress bone marrow function.

The client is experiencing low back pain and is to have an aquathermia pad applied. The nurse recognizes that safe application of heat to a client's injury includes: 1. Providing a timer for the client 2. Allowing the client to adjust the temperature for comfort 3. Placing the pad directly onto the area requiring treatment 4. Using the highest temperature that is tolerated by the client

ANS: 1 An application should last only 20 to 30 minutes. Providing a timer for the client will help prevent injury to the tissue. The temperature setting is fixed by inserting a plastic key into the temperature regulator. In many institutions the central supply room sets the regulators to the recommended temperature. The nurse does not place the pad directly on the client's skin. To prevent injury, it should be covered with a thin towel or pillow case. The recommended temperature is 105° to 110° F. The pad should not be used at the highest temperature that is tolerated by the client.

Which of the following interventions is mostly likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose? 1. Turn and position the client at least every 2 hours. 2. Use a lift sheet when moving the client up in the bed. 3. Change wet, soiled clothing as promptly as it is detected. 4. Keep the head of the client's bed elevated to less than 30 degrees.

ANS: 1 Pressure is the major cause in pressure ulcer formation, and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pressure

When changing the soiled linen on the bed of a client who is comatose, the nurse notices a reddened, blanchable area approximately 2 cm in diameter on her left buttock. The nurse's initial skin breakdown intervention is to: 1. Position the client on her right side 2. Finish providing fresh, dry linen to the client's bed 3. Include a 2-hour turning schedule in the client's care plan 4. Measure the area in order to describe it in the nurses' notes

ANS: 1 Pressure is the major cause in pressure ulcer formation, and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pressure. The remaining options are appropriate, but none has priority over proper positioning of the client.

Upon changing the client's dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is: 1. Sterile saline 2. Hydrogen peroxide 3. Povidone-iodine (Betadine) 4. Sodium hypochlorite (Dakin's solution)

ANS: 1 Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic, such as normal saline. Normal saline will not damage or kill cells, such as fibroblasts and healing tissue. Hydrogen peroxide, povidone-iodine (Betadine), and sodium hypochlorite (Dakin's solution) are cytotoxic and therefore should not be used to clean a wound that is granulating.

Following a head injury, the client has thin drainage coming from the left ear. The nurse describes this drainage as: 1. Serous 2. Purulent 3. Cerebrospinal fluid 4. Serosanguineous

ANS: 1 Serous drainage is clear, watery plasma. Purulent drainage is thick, yellow, green, tan, or brown. Drainage must be tested to determine if it is cerebrospinal fluid. The nurse should describe the drainage by its appearance (i.e., serous). Serosanguineous drainage is pale, red, and watery, a mixture of clear and red fluid.

Which of the following assessment findings is most representative of a stage II pressure ulcer? 1. A blister 2. Undermining 3. Nonblanchable redness 4. Visible subcutaneous fat

ANS: 1 Stage II ulcers have partial-thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. The remaining options describe elements of stage I and stage III ulcers.

The 23-year-old female client is concerned about scarring from her hernia surgery. She had a third-degree burn on her right arm when she was younger that left a scar that she is self-conscious about. Then nurse explains to the client that the wound from the burn healed differently than the surgical incision will heal. The incision that she will have will heal by: 1. Primary intention 2. Secondary intention 3. Tertiary intention 4. Dehiscence

ANS: 1 The surgical wound heals by primary intention. The skin edges are approximated, or closed, and the risk for infection is low. Healing occurs quickly; with minimal scar formation, as long as infection and secondary breakdown is prevented. Healing occurs by epithelialization. A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by secondary intention. The wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention, and thus the chance of infection is greater. In tertiary intention, a wound is left open for several days, then wound edges are approximated. This type of healing is for wounds that are contaminated and require observation for signs of inflammation. Closure of wound is delayed until risk for infection is resolved. When a wound fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury). Dehiscence is the partial or total separation of wound layers.

Which of the following clients have an increased risk for the development of a pressure ulcer? (Select all that apply.) 1. A 35-year-old motorcycle accident victim who has been comatose for 5 months 2. A 75-year-old client with type 2 diabetes with neuropathy in his feet 3. A 64-year-old client experiencing anorexia after hip replacement surgery 4. A 70-year-old client diagnosed with advanced Alzheimer's disease 5. A 40-year-old client with osteoarthritis who has been in bed with the flu 6. A 25-year-old client in the terminal stages of brain cancer

ANS: 1, 2, 3, 4, 6 Any client experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development. The only option that does not represent one of the risk factors is the client dealing with the flu.

Which of the following statements best reflects the nurse's role in the health and maintenance of a client's skin? (Select all that apply.) 1. "I'll note on the client's care plan to apply lotion to her dry elbows." 2. "I'm on my way in to turn the client. Will you be able to help me?" 3. "The ancillary staff tells me that her skin is generally very dry." 4. "The pressure ulcer on her hip has really gotten smaller." 5. "Can you bring in some scented lotion for your mom?" 6. "A 1.5-cm reddened area noted on client's left heel."

ANS: 1, 2, 4, 6 One of the nurse's most important responsibilities is to monitor skin integrity and to plan, implement, and assess interventions to maintain skin integrity. The remaining options do not reflect nursing interventions—one reflects ancillary staff, and the other does not really mention the therapeutic role of the request.

A client requires wound debridement. The nurse is aware that which one of the following statements is correct regarding this procedure? 1. It allows the healthy tissue to regenerate. 2. When performed by autolytic means, the wound is irrigated. 3. Mechanical methods involve direct surgical removal of the eschar layer of the wound. 4. Enzymatic debridement may be implemented independently by the nurse whenever it is required.

ANS: 2 Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base necessary for healthy tissue to regenerate. Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. The wound is not irrigated. Mechanical methods include wet-to-dry dressings, wound irrigation, and whirlpool treatments. Surgical debridement involves direct surgical removal of the eschar layer of the wound. Enzymatic debridement requires a health care provider's order.

The client is brought into the emergency department with a knife wound. The nurse correctly documents the client's wound as a(n): 1. Contusion wound 2. Clean wound 3. Acute wound 4. Intentional wound

ANS: 3 A client with a knife wound is an example of an acute wound. An acute wound is caused by trauma from a sharp object. A contusion is a closed wound caused by a blow to the body by a blunt object, resulting in a bruise. A clean wound is a wound that contains no pathogenic organisms, such as a closed surgical wound that does not enter the gastrointestinal, respiratory, or genitourinary system. An intentional wound is a wound resulting from therapy, such as a surgical incision.

The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the client's skin integrity? 1. Having the client sit up in a chair for 4-hour intervals 2. Keeping the head of the bed in a high-Fowler's position to increase circulation 3. Keeping a written schedule of turning and positioning 4. Encouraging the client to perform pelvic muscle training exercises several times a day

ANS: 3 The frequency of repositioning should be individualized for the client; however, clients should be repositioned at least every 2 hours. The Agency for Healthcare Research and Policy (AHRQ) guidelines recommend that a written turning and positioning schedule be used. Clients able to sit in a chair should be limited to sitting for 2 hours or less. Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. Pelvic muscle training may help prevent incontinence, but it is not the best intervention for maintaining the client's skin integrity.

The nurse is assessing a 78-year-old female African-American client with dark skin. When assessing the skin, the nurse knows to avoid which source of light because it can cast a bluish hue on the skin, making the assessment difficult? 1. Natural sunlight 2. Halogen light 3. Florescent light 4. Incandescent light

ANS: 3 The nurse should avoid a fluorescent light source when assessing dark skin because it casts a bluish hue, making accurate assessment difficult.

The nurse determines that the client's wound may be infected. To perform an aerobic wound culture, the nurse should: 1. Collect the superficial drainage 2. Collect the culture before cleansing the wound 3. Obtain a culturette tube and use sterile technique 4. Use the same technique as for collecting an anaerobic culture

ANS: 3 The nurse uses different methods of specimen collection for aerobic or anaerobic organisms. To collect an aerobic wound culture, the nurse uses a sterile swab from a culturette tube and sterile technique. The nurse never collects a wound culture sample from old or superficial drainage. Resident colonies of bacteria from the skin grow in superficial drainage and may not be the true causative organisms of a wound infection. The nurse should clean a wound first with normal saline to remove skin flora before obtaining the culture.

A client with a large abdominal wound requires a dressing change every 4 hours. The client will be discharged to the home setting, where the dressing care will be continued. Which of the following is true concerning this client's wound healing process? 1. An antiseptic agent is best followed with a rinse of sterile saline solution. 2. A heat lamp should be used every 2 hours to rid the wound area of contaminants. 3. Sterile technique should be emphasized to the client and family. 4. A dressing covering will allow the wound area to remain moist.

ANS: 4 A dressing should support a moist wound environment if the wound is healing by secondary intention, such as with a large abdominal wound. A moist wound base facilitates the movement of epithelialization, thus allowing the wound to resurface as quickly as possible. Only mild soap may be used or saline. Antiseptics may be damaging to granulation tissue. A heat lamp should not be used because it will dry out the wound and impair the movement of epithelialization. Clean dressings may be used in the home setting.

The nurse is concerned that the client's midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication? 1. Administering antibiotics to prevent infection 2. Using appropriate sterile technique when changing the dressing 3. Keeping sterile towels and extra dressing supplies near the client's bed 4. Placing a pillow over the incision site when the client is deep breathing or coughing

ANS: 4 A strategy to prevent dehiscence is to use a folded thin blanket or pillow placed over an abdominal wound when the client is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure. A client who has an infection is at risk for poor wound healing and dehiscence. However, prophylactic use of antibiotics is not the best intervention to prevent dehiscence. Using appropriate sterile technique is always important to prevent the development of infection but is not the best intervention to prevent dehiscence.

The client requires support, and an abdominal binder is ordered. The nurse correctly implements the use of a binder by: 1. Using it as a replacement for underlying dressings 2. Keeping it loose for client comfort 3. Having the client sit or stand when it is applied 4. Making sure the client has adequate ventilatory capacity

ANS: 4 After applying the binder, the nurse should assess the client's ability to ventilate properly, including deep breathing and coughing. Wounds should be entirely covered with dressings; the binder is applied over the dressing. The binder should not be loose, or it will be ineffective in providing support. The client should be lying supine with head slightly elevated and knees slightly flexed for application of the abdominal binder.

The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by: 1. Filling two thirds of the wound cavity 2. Leaving saline-soaked folded gauze squares in place 3. Putting the dressing in very tightly 4. Extending only to the upper edge of the wound

ANS: 4 The wound should be packed only until the packing material reaches the surface of the wound. Wound packing that overlaps onto the wound edges can cause maceration of the tissue surrounding the wound. It can also impede the proper healing and closing of the wound. The wound should be packed to the upper edge of the wound to prevent dead space and the formation of abscesses. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. The wound should not be packed too tightly. Overpacking the wound may cause pressure on the tissue in the wound bed.

Which nursing entry is most complete in describing a client's wound? 1. Wound appears to be healing well. Dressing dry and intact. 2. Wound well approximated with minimal drainage. 3. Drainage size of quarter; wound pink, 4 × 4s applied. 4. Incisional edges approximated without redness or drainage; two 4 × 4s applied.

ANS: 4 This is the most complete description of the client's wound. It describes the wound according to characteristics observed and the dressing that covers it. Wounds should be measured using the metric system, not described as the size of objects.

The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape: 1. At a 45-degree angle to the skin surface while pulling away from the wound 2. At a right angle to the skin surface while pulling toward the wound 3. At a right angle to the skin surface while pulling away from the wound 4. Parallel to the skin surface while pulling toward the wound

ANS: 4 To remove tape safely, the nurse loosens the tape ends and gently pulls the outer end parallel with the skin surface toward the wound. Tape should not be pulled in a direction away from the wound because this may cause the wound edges to separate. Holding the tape at a right angle to the skin surface may pull on the wound bed, causing separation of wound layers, or may damage the underlying skin.