Skin Integrity and Wound Care Prep U

A physician orders a wound irrigation to apply an antiseptic to a client's wound. The nurse will follow which guideline for performing this procedure? a) If bleeding is noted that was not previously there, the nurse should continue irrigation and then notify the physician. b) Sterile water is often the solution of choice when irrigating wounds. c) If the wound is closed, clean technique may be used instead of sterile technique. d) When the solution from the wound turns light pink, the irrigation should be stopped.

If the wound is closed, clean technique may be used instead of sterile technique. Explanation: Wounds are cleaned initially and before applying any new dressing and are also irrigated to apply local heat or an antiseptic to an area. Wound irrigation is a directed flow of solution over tissues. Sterile equipment and solutions are required for irrigating an open wound. Nonsterile solutions and technique are generally used to clean the skin surface if the wound edges are approximated or closed. Saline solution is the common solution of choice when performing an irrigation. When the solution from the wound turns clear, the irrigation should be discontinued. If bleeding is noted that was not previously there, the nurse should stop the irrigation and notify the physician

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage? a) in the axilla b) under the client c) on the output sheet d) under the skin

under the client Explanation: The amount and color of wound drainage depends on the size and location of the wound. Drainage can be assessed on the wound, on the dressings, in drainage collection devices, or under the client.

A nurse is evaluating a client's laboratory data. Which of the following laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development? a) Hemoglobin A1C 5% b) Albumin 2.8 mg/dL c) Blood urea nitrogen (BUN) 7 mg/dL d) White blood cell count 14,800 mm3

Albumin 2.8 mg/dL Explanation: An albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure ulcer. 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.

During a skin assessment, the nurse recognizes the first indication that a pressure ulcer may be developing when the skin is which color during the application of light pressure? a) White b) Yellow c) Blue-grey d) Red

Red Explanation: Nonblanching erythema is one of the earliest signs of impending skin breakdown.

Question: The nurse is preparing to irrigate a client's wound. Arrange the following steps in the correct order. 1 Fill the irrigation syringe with warmed irrigation solution. 2 Don a mask, gown, and eye protection. 3 Carefully remove the soiled dressing. 4 Dry the surrounding skin with gauze dressings. 5 Gently direct a stream of solution into the wound. 6 Don sterile gloves.

Don a mask, gown, and eye protection. Carefully remove the soiled dressing. Don sterile gloves. Fill the irrigation syringe with warmed irrigation solution. Gently direct a stream of solution into the wound. Dry the surrounding skin with gauze dressings. Explanation: A hydrocolloid dressing in not indicated.

Question: The nurse is caring for a client who has a stage IV pressure ulcer. 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

Hemostasis Inflammatory Proliferation Maturation Explanation: The correct order of wound healing phases is hemostasis, inflammatory, proliferation, and maturation.

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? a) Secondary intention b) Primary intention c) Tertiary intention d) Desiccation

Secondary intention Explanation: The client with a wound dehiscence will undergo wound repair by secondary intention. In these wounds, the wound edges are not well approximated and will require more tissue replacement. Primary intention involves wound edges that are well approximated or close together. Tertiary intention involves wounds that are left open for a period of time and then closed. Desiccation is a process where cells are dehydrated. This leads to cell death and delays healing.

A nurse assessing the skin of clients knows that the following are health states that may predispose clients to skin alterations. Select all that apply. a) Excessive perspiration b) Low BMI c) Obesity d) Hypertension e) Cataracts

• Low BMI • Obesity • Excessive perspiration Explanation: Very thin (low BMI) and very obese people tend to be more susceptible to skin irritation and injury. Excessive perspiration, often associated with being ill, predisposes the skin to breakdown, especially in skin folds. Jaundice, a condition caused by excessive bile pigments in the skin, results in a yellowish skin color. The skin is often itchy and dry, and clients with jaundice are more likely to scratch their skin and cause an open lesion with the potential for infection.

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 alternate between positive and negative pressure every 2 hours." b) "I will squeeze the chamber and apply the cap to maintain negative pressure." c) "I will apply a dressing at the end of the drain to catch any drainage." d) "I will check and empty the drain every 6 hours."

"I will squeeze the chamber and apply the cap to maintain negative pressure." Explanation: The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless it is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain uses gauze at the end of the drain to catch drainage.

A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound? a) Stage III b) Suspected deep tissue injury c) Stage II d) Unstageable

Suspected deep tissue injury Explanation: A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial thickness loss of dermis that often presents as an open blister. A stage III pressure ulcer is a full-thickness tissue loss in which subcutaneous tissue is visible. An unstageable wound is covered by slough or eschar. The depth of the wound is unknown because of this covering.

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. a) Use a sterile applicator to apply any ointment that is ordered. b) Avoid touching the wound bed, whether with gloves or forceps. c) Clean the wound from top to bottom. d) Clean from the outside of the wound to the center. e) Use a new gauze for each wipe of the wound.

• Clean the wound from top to bottom. • Use a sterile applicator to apply any ointment that is ordered. • Use a new gauze for each wipe of the wound. • Avoid touching the wound bed, whether with gloves or forceps. Explanation: Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps.

Question: A nurse is caring for a client who has a Jackson-Pratt drain. Which of the following is the order in which the nurse should carry out these interventions? 1.Fully compress the chamber and replace the cap 2.Measure and record the character and amount of drainage 3.Use a gauze pad to clean the drain's outlet 4.Empty the drain chamber's contents 5.Change dressing to drain site 6.Change gloves

Empty the drain chamber's contents Use a gauze pad to clean the drain's outlet Fully compress the chamber and replace the cap Measure and record the character and amount of drainage Change gloves Change dressing to drain site Explanation: The order in which the Jackson Pratt drain should be cared for is emptying the chamber's contents, using a gauze pad to clean the drain's outlet, fully compressing the chamber and replacing the cap, measuring and recording the character and amount of drainage, changing gloves, and changing dressing to drain site.

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) Enzymatic debridement b) Biosurgical debridement c) Mechanical debridement d) Autolytic debridement

Mechanical debridement Explanation: Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? a) Reduce the time interval between dressing changes. b) Assure that the packing material is completely saturated when placed in the wound. c) Use less packing material. d) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.

Reduce the time interval between dressing changes. Explanation: Reducing the time interval between the dressing changes allows for the dressing change to occur without causing pain and promoting secondary intention. If the dressing becomes dry, the more pain the client experiences and damage to the newly formed epithelial and granulating tissue. The packing material should be completely saturated when placed in the wound. Using less packing material impairs secondary intention. A hydrocolloid dressing is not indicated.

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day? a) The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain. b) The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain. c) The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. d) The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain.

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. Explanation: Sometimes the physician orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site.

A nurse is caring for a client with a nonhealing stage IV pressure ulcer. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition? a) Tunneling b) Undermining c) Dehiscence d) Eschar

Undermining Explanation: Undermining is the term for a hollow area between the outer wound and the wound bed. It resembles a cave. Eschar is a leathery covering that is dead tissue and is usually removed by debridement. Tunneling is a cavity or channel formed from a wound. Dehiscence is the opening of a previously closed surgical wound.

A woman 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. The client has a(an): a) infection. b) dehiscence. c) evisceration. d) fistula.

fistula. Explanation: A fistula is an abnormal tubelike passageway that forms from one organ to outside the body.

Which clients would be considered at risk for skin alterations? Select all that apply. a) a homosexual in a monogamous relationship b) a client receiving radiation therapy c) a teenager with multiple body piercings d) a client with diabetes e) a client undergoing cardiac monitoring

• a teenager with multiple body piercings • a client receiving radiation therapy • a client with diabetes Explanation: Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a homosexual relationship with multiple partners would also place a client at risk for HIV and skin alterations. Cardiac monitoring and respiratory disorders are not risk factors.

A nurse is caring for a client who has recently undergone hernial surgery. What are possible causes of complications with regard to surgical wounds? Select all that apply. a) distension of the abdomen from accumulated intestinal gas b) compromised blood circulation c) weak tissue and muscular support due to obesity d) Serous fluid accumulation prevents skin tissue approximation. e) insufficient protein and vitamin C intake Submit your answer

• insufficient protein and vitamin C intake • weak tissue and muscular support due to obesity • distension of the abdomen from accumulated intestinal gas Explanation: The nurse should remember that insufficient protein and vitamin C intake, weak tissue, muscular support due to obesity, and distension of the abdomen from accumulated intestinal gas are the 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; or compromised tissue integrity from previous surgical procedures in the same area are some of the other causes of surgical complication. Compromised blood circulation and serous fluid accumulation that prevents skin tissue approximation are the factors that interfere with wound healing.

Which action should the nurse perform when applying negative pressure wound therapy? a) Irrigate the wound thoroughly using normal saline and clean technique. b) Test the seal of the completed dressing by briefly attaching it to wall suction. c) Increase the negative pressure setting until drainage is brisk. d) Cut foam to the shape of the wound and place it in the wound.

Cut foam to the shape of the wound and place it in the wound. Explanation: When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care the nurse notes the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize with this client's wound? a) Proliferation Phase b) Maturation Phase c) Hemostasis d) Inflammatory Phase

Proliferation Phase Explanation: The wound description reveals a beefy red wound bed that bleeds easily. This is the proliferation stage and describes granulation tissue. Hemostasis is the initial phase that involves activation of platelets. The inflammatory phase involves white blood cells and macrophages entering the wound to remove debris from the wound. The maturation phase involves collagen remodeling and scar formation.

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments? a) Implement nursing interventions for Altered Skin Integrity. b) Recognize that this is ischemia, followed by reactive hyperemia. c) Document the presence of a pressure ulcer and develop a care plan. d) Immediately report to the physician that the client has a pressure ulcer.

Recognize that this is ischemia, followed by reactive hyperemia. Explanation: Blanching of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer.

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) Maintains a moist environment b) Keeps the wound clean c) Reduces swelling and inflammation d) Supports the area around the wound

Supports the area around the wound Explanation: Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wound on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist.

A client has developed blisters around the tape that secures the dressing. The nurse should: a) apply tape to the side of the blisters. b) use Montgomery straps. c) apply skin barrier to protect skin. d) apply the dressing with a binder.

apply the dressing with a binder. Explanation: Bandages, binders, and stretch nets also can be used to hold gauze dressings in place.

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery? a) period during which new cells fill and seal a wound b) physiologic defense immediately after the tissue injury c) process by which damaged cells recover and reestablish normal function d) period during which the wound undergoes changes and maturation

period during which the wound undergoes changes and maturation Explanation: The remodeling phase can be described as the period during which the wound undergoes changes and maturation. The remodeling phase follows the proliferative phase and may last for 6 months to 2 years. The inflammatory phase is the physiologic defense immediately after tissue injury. The proliferation phase is the period during which new cells fill and seal the wound. Resolution is the process by which damaged cells recover and reestablish normal function. This forms part of the proliferation phase.

Which education points would the nurse use to explain the development of pressure ulcers to clients and how to prevent them? Select all that apply. a) "Most pressure ulcers occur over the trochanter and calcaneus." b) "The major predisposing factor for a pressure ulcer is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues." c) "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation." d) "The skin can tolerate considerable pressure without cell death, but for short periods only." e) "Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." f) "Generally, a pressure ulcer will not appear within the first 2 days in a person who has not moved for an extended period of time." Submit your answer

• "Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." • "The skin can tolerate considerable pressure without cell death, but for short periods only." • "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation." Explanation: Pressure ulcers usually occur over bony prominences. The skin can tolerate considerable pressure without cell death, but for short periods only. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation. Pressure ulcers can develop in a variety of locations where bony prominences are located. The most common are the coccyx and sacrum. A pressure ulcer can appear in less than 2 hours of time, depending on the factors present. Most pressure ulcers develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.

The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which of the following statements made by students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply. a) "The kidneys react to hypovolemia by stimulating fluid retention." b) "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." c) "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." d) The adrenal glands regulate blood volume by secreting aldosterone." e) "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids."

• "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." • "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." • The adrenal glands regulate blood volume by secreting aldosterone." • "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." Explanation: The heart and blood vessels react to hypovolemia by stimulating fluid retention rather than the kidneys. The other statements made by the students are correct.

Which interventions might a nurse be expected to perform when providing competent care for a client with a draining wound? Select all that apply. a) Apply a nonabsorbent material over the first layer of absorbent material. b) Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. c) Apply an absorbent dressing material as the first layer of the dressing. d) Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. e) Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. f) Change the dressing midway between meals. Submit your answer

• 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. Explanation: 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 medical-surgical nurse is assessing wounds of clients. Which wound complications are accurately described below? Select all that apply. a) Evisceration, which occurs when the viscera protrudes through the incisional area b) Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site c) Dehiscence, which is present when there is a partial or total disruption of wound layers d) a wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5, which is a sign of an impending evisceration e) symptoms of wound infection, which are usually apparent within 1 to 2 weeks after the injury or surgery f) delayed wound healing in clients who are thin and at greater risk for complications owing to a thinner layer of tissue cells

• Dehiscence, which is present when there is a partial or total disruption of wound layers • Evisceration, which occurs when the viscera protrudes through the incisional area • Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site Explanation: Dehiscence is a partial or total disruption of wound layers. Evisceration occurs when the viscera protrudes through the incisional area. Postoperative fistula formation commonly manifests by drainage from an opening in the skin or surgical site. Symptoms of wound infection occur before 1 to 2 weeks after the injury or surgery. Delayed wound healing in clients who are thin and at greater risk for complications is not due to thinner layer of tissue cells, but possibly from malnutrition, or other complications. An increase in the flow of serosanguineous fluid between postoperative days 4 and 5 would be a sign of an impending dehiscence, not evisceration.

Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a client's wound? Select all that apply. a) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. b) Put on clean gloves and squeeze excess fluid from the gauze dressing before packing it tightly in the wound. c) Apply one dry, sterile gauze pad over the wet gauze, and then place an ABD pad over the gauze pad. d) Using clean technique, open the supplies and dressings and place the fine-mesh gauze into the basin, pouring the ordered solution over the mesh to saturate it. e) Position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. f) Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape.

• Position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. • Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. • Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. Explanation: The nurse would position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. The nurse would carefully and gently remove the soiled dressings and use an adhesive remover to help remove the tape, if necessary. The nurse would gently press to loosely pack the wound, using forceps or cotton-tipped applications to press the gauze into all the wound surfaces. The nurse would squeeze excess fluid from the gauze dressing but would pack it lightly, not tightly in the wound. The nurse would use more than one dry, sterile gauze over the wet gauze. The nurse would use sterile technique, not clean technique for the dressing process.

A nurse assessing client wounds would document which examples of wounds as healing normally without complications? Select all that apply. a) The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. b) incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes c) a wound that does not feel hot upon palpation d) a wound that forms exudate due to the inflammatory response e) a wound that takes approximately 2 weeks for the edges to appear normal and heal together f) a wound with increased swelling and drainage that may occur during the first 5 days of the wound healing process

• 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 upon palpation • a wound that forms exudate due to the inflammatory response Explanation: 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.

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply. a) The nurse makes more frequent checks of the skin of an older adult using a heating pad. b) The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. c) The nurse places a heating pad on a sprained wrist that is in the acute stage. d) The nurse fills an ice bag with small pieces of ice to about two-thirds full. e) The nurse applies moist cold to a client's eye for 40 minutes every 2 hours. f) The nurse instructs the client to lean or lie directly on the heating device.

• The nurse fills an ice bag with small pieces of ice to about two-thirds full. • The nurse makes more frequent checks of the skin of an older adult using a heating pad. • The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. Explanation: The nurse would make more frequent checks of the skin of an older adult using a heating pad. The nurse would fill an ice bag with small pieces of ice to about two-thirds full. The nurse would cover a cold pack with a cotton sleeve to keep it in place on an arm. The nurse would place cold therapy, not a heating pad, on a sprained wrist in the acute stage. The nurse would instruct the client not to lie or lean directly on the heating device. The nurse would apply moist cold to a client's eye for 30 minutes, not 40 minutes, every 2 hours.

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? Select all that apply. a) Use povidone-iodine or hydrogen peroxide to irrigate and clean the ulcer. b) Clean the wound with each dressing change using aggressive motions to remove necrotic tissue. c) Pack wound cavities densely with dressing material to promote tissue healing. d) Keep the ulcer tissue moist and the surrounding skin dry. e) Use a dressing that absorbs exudate but maintains a moist healing environment. f) Use whirlpool treatments, if ordered, until the ulcer is considered clean.

• Use whirlpool treatments, if ordered, until the ulcer is considered clean. • Keep the ulcer tissue moist and the surrounding skin dry. • Use a dressing that absorbs exudate but maintains a moist healing environment. Explanation: The nurse would use whirlpool treatments, if ordered, until the ulcer is considered clean. The nurse would keep the ulcer tissue moist and the surrounding skin dry. The nurse would use a dressing that absorbs exudate but maintains a moist healing environment. The nurse would not use aggressive motions to remove necrotic tissue. Aggressive motions could cause damage to healthy tissue present in the wound. The nurse would use normal saline, not povidone-iodine or hydrogen peroxide, to irrigate and clean the ulcer. The nurse would not pack the wound cavities densely, rather loosely, to promote tissue healing.