skin integrity
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?
"Dehiscence is when a wound has partial or total separation of the wound layers."
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?
"I will put a layer of cloth between my skin and the ice pack."
The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?
"Reinforced adhesive skin closures will hold my wound together until it heals."
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
"Very little scar tissue will form."
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
Clean the wound from the top to the bottom and from the center to outside.
After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse?
Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.
The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?
Impaired tissue integrity
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?
Incision
Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?
Local capillary pressure must be lower than external pressure
A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?
Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?
The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?
cleanse with a new gauze for each stroke
Which is not considered a skin appendage?
connective tissue
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
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?
a sterile, flexible applicator moistened with saline
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?
contusion
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
The nurse would recognize which client as being particularly susceptible to impaired wound healing?
an obese woman with a history of type 1 diabetes
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?
braden scale
The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?
evisceration
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?
fish
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?
incision
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?
preventing the client from sliding in bed
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 that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound?
proliferation phase
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
removing dead or infected tissue to promote wound healing
A 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
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 new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:
to apply sunscreen when exposed to ultraviolet rays.
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
true
