Skin Integrity and wound care practice quiz

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated and WBCs move into the wound. The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation, when WBCs move into the wound. Granulation and collagen deposition are initiated not in the inflammatory process but rather in the healing phase. Bleeding occurs in the injury phase.

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage. After completing a dressing change and retuning the client to a comfortable position, it is important to document color, odor, amount, and the type of wound drainage. Early documentation helps to assure the most accurate information can be recorded. Determining the extent of wound undermining and measuring length, width, and depth of the wound should be performed during the dressing change, while the wound is still exposed. The healthy tissue surrounding the wound should never be massaged because it could cause further breakdown of healthy tissue.

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should the nurse prioritize in order to minimize the client's chance of skin breakdown?

repositioning the client on a regular basis It is imperative to regularly turn and reposition the client who is immobile in order to prevent ischemia and consequent skin breakdown. Hydration is also necessary to maintain skin integrity, but dehydration is less of a risk factor than is prolonged immobility. It is unnecessary to keep the client upright, such as in the semi-Fowler or high Fowler position, in order to protect the skin. Massage may promote circulation, but it is less important than turning the client on a scheduled basis.

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?

"I will restrict my diet to fats and carbohydrates." Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and proteins are necessary to rebuild cells and tissues. Vitamins C and D, zinc, and adequate fluids are also necessary for wound healing.

A nurse caring for a client who has a surgical wound after a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?

There is an unintentional separation of the wound. With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together. Edema is an accumulation of fluid in the interstitial tissue. Redness or inflammation of an area as a result of dilation is erythema.

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

assisting the client in moving to prevent strain on the suture line The proliferative phase of wound healing begins within 2 to 3 days of the injury. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations. Pain medication assists with the pain and not with the wound healing process. Fever is not a normal response. A scar will occur later in the wound healing process and usually does not limit the joint movement.

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound?

stage II pressure injury Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.

The nurse is caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states, "My pain medication is effective, but will this pain ever get better and go away?" Which response is correct?

"Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." Surgical incisional pain is usually most severe for the first 2 to 3 days and then progressively diminishes. It is imperative that nurses teach clients about the progression of pain postsurgery. The client should still be assessed for pain and the pain scale should be documented in the client's medical record. The development of chronic pain is persistent pain after 6 months.

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply.

-Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. -Change the dressing midway between meals. -Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. The nurse would administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. The medication would be in the client's system at the time of the dressing change. The nurse would change the dressing midway between meals so that pain and discomfort would be at a minimum at the time of the meal. A protective paste or ointment would protect the surrounding skin from the drainage of the wound. There is no need to apply another layer of protective ointment or paste on top of the previous layer when changing dressings. The nurse would not apply an absorbent dressing material as the first layer of the dressing. The nurse wants to wick the drainage from the wound. The nurse would not apply a nonabsorbent material over the first layer of absorbent material. Again, the nurse wants to wick the drainage from the wound.

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply.

-The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. -a wound that does not feel hot and tender upon palpation -a wound that forms exudate due to the inflammatory response The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. This would be a correct way to document a normally healing wound. A wound that does not feel hot upon palpation would be another example of correctly documenting a wound that has no complications. A wound that is warm to touch is not an abnormal finding. A wound that forms exudate due to the inflammatory response would be correct documentation of a normal finding.

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.

-insufficient protein and vitamin C intake -weak tissue and muscular support due to obesity -distention of the abdomen from accumulated intestinal gas The nurse should remember that insufficient protein and vitamin C intake, weak tissue, muscular support due to obesity, and distention of the abdomen from accumulated intestinal gas are likely causes of surgical complications. Premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; and compromised tissue integrity from previous surgical procedures in the same area are some of the other causes of surgical complications. Compromised blood circulation and serous fluid accumulation that prevents skin tissue approximation are factors that interfere with wound healing.

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care?

An older adult An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. The progress is based on metabolic changes, with the very young such as an infant healing faster, followed by the young adult, and then middle adult.

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?

Desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care for dressing changes?

Increases the risk of infection by contaminating the wound Using the mouth to blow air into a wound bed or to dry the wound edges does not adhere to the standards of care or of ethics for nurses. This action will increase the risk of wound contamination and the wound is more likely to become infected as our mouths and the air we blow out harbors many kinds of bacteria that can adhere to the wound and increase the risk for infection and contamination. Every effort should be taken into consideration to use sterile equipment, solutions and medical aseptic, or clean technique to remove old dressings. Coolness to a site decreases blood flow and to heal a wound more blood flow to the site assists with healting and reducing the risk of infection. Blowing on a wound bed may cause a uncomfortable sensation to the skin or funny sensation but it will not reduce the risk of the infection. The effect of the blowing sensation and contaminants in to the wound bed demonstrates non-adherence to the standards of safe and effective wound care and management.

When measuring the size, depth, and wound tunneling of a client's stage IV pressure injury, what action should the nurse perform first?

Perform hand hygiene. Hand hygiene should precede any wound assessment or wound treatment. Performing hand hygiene prior to the wound assessment reduces the risk for infection. Inserting a swab into the wound at 90 degrees, measuring the width of the wound with a disposable ruler, and assessing the condition of the visible wound bed are all appropriate wound assessments.

The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, the nurse will incorporate which nursing measure?

Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. The nurse should plan to administer a prescribed analgesic 30 to 45 minutes prior to changing the dressing. Analgesic administration immediately prior to a dressing change will not allow the analgesic to reach its maximum pain control impact. When clients are fatigued, the sensation of pain may be greater. Also, plan to change the dressing midway between meals so that the client's appetite and mealtimes are not disturbed.

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure?

Red Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply.

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 stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take?

The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour. An observation of a reddened area on a client's skin that doesn't blanch after pressure is relieved is characteristic of a first-degree pressure injury. This indicates that the current nursing intervention of turning and repositioning the client every 2 hours to prevent impaired skin integrity is inadequate. The client's nursing care plan needs to be revised to reflect the new assessment finding of an actual pressure injury. Additionally, new nursing interventions need to be implemented to turn and reposition the client hourly to relieve the pressure on the trochanter ulcer and prevent the formation of new pressure injuries. Repositioning the client to the client's back, documenting the intervention, reassessing the client's right trochanter in 2 hours, and documenting the condition of the skin in the medical record all fail to update the nursing care plan and revise the interventions to a more frequent turning and repositioning schedule.

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

An 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 transparent film Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms. Gauze dressings--precut, with an adherent coating, premedicated with antibiotics--do not allow the nurse to visualize the site without partially or completely removing the dressing.

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and:

covering the wound area with sterile towels moistened with sterile 0.9% saline. If dehiscence occurs, the nurse should cover the wound area with sterile towels moistened with sterile 0.9% saline. The nurse should also place the client in the low Fowler position and cover the exposed abdominal contents with sterile saline, not hydrogen peroxide. The nurse notifies the health care provider immediately, because this is a medical emergency. The nurse should not leave the client alone but does not need to hold the wound together until the health care provider arrives.

Which type of wound drainage should alert the nurse to the possibility of infection?

foul-smelling drainage that is grayish in color Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection.

A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected?

full-thickness skin loss A stage IV pressure injury is characterized by the extensive destruction associated with full-thickness skin loss. At stage II, the skin breaks open, wears away, or forms an ulcer or blister, which is usually tender and painful. Slough or eschar may be present on some parts of the wound bed in stage IV but not always. Skin pallor occurs in stage I.

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

proliferation phase The proliferation phase is characterized by the formation of granulation tissue (highly vascular red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about 4 to 6 days; white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms.

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

A client comes to the emergency department after falling off a skateboard onto the sidewalk. Which assessment data, consistent with an abrasion, would the nurse expect to see?

scraping off of surface layers of skin An abrasion involves stripping of layers on the skin's surface. Therefore the nurse anticipates seeing an abrasion on the basis of the description of the incident. An incision involves a clean separation of skin and tissue with smooth, even edges. An avulsion has stripped-away large areas of skin and underlying tissues, leaving bone and cartilage exposed. A puncture is a skin opening caused by a sharp, pointed object.

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?

stage III pressure injury Damage to the subcutaneous tissue indicates a stage III pressure injury. Extensive destruction associated with full-thickness skin loss is categorized as a stage IV pressure injury. A stage I pressure injury is a defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in more darkly pigmented skin. A stage II pressure injury is superficial and may present as a blister or abrasion.