Skin integrity/Wound Care Practice Questions

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply.

-Use standard precautions or transmission-based precautions when indicated. -Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. -Clean to at least 1 in beyond the end of the new dressing if one is being applied.

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a. Notify the health care provider of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. c. Place the patient in the low Fowler's position.

c,b,a

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?

hemostasis phase

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"It provides a way to remove drainage and blood from the surgical wound."

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."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

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

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

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

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

Keep the swab and the inside of the culture tube sterile.

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 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 2

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient?

The therapy provides a moist environment and stimulates blood flow to the wound.

A client with anorexia nervosa has developed a pressure injury on the sacrum. Which laboratory result would indicate the client is at nutritional risk?

Total lymphocyte count of 1,500/mm3 (1.50 x 109/L)

T/F Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues

True

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury?

Using a mild cleansing agent when cleansing the skin

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 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

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

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

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

In the older adult client, wrinkling is related to:

loss of elasticity.

The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot and injured the worker's foot. What type of injury does the nurse anticipate?

puncture

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:

second degree or partial thickness

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury/

stage IV

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent

A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate?

Disturbed Body Image

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan?

Document the findings and continue to monitor the patient.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation

"I should see less swelling and redness with the cold treatment."

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 caring for a client with a knee sprain. Which client statement regarding use of an ice pack indicates that nursing teaching has been effective?

"I will put a washcloth between my knee and the ice pack."

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply.

-Decreased effectiveness of antibiotics against the bacteria -Decreased effectiveness of the patient's normal immune process

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

Discontinue the therapy and assess the client.

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended?

Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?

Performing careful hand hygiene

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 uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound?

Provide gentle cleansing of the wound.

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as:

Stage 2

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?

State 3

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

Stop removing staples and inform the surgeon

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

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 evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue

Which is not considered a skin appendage?

connective tissue

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

dehiscence

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

elevating and supporting the stump

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

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

secondary intention

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?

serosanguineous

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

serosanguineous

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply.

-Hemostasis occurs immediately after the initial injury. -White blood cells move to the wound in the inflammatory phase. -During the inflammatory phase, the patient has generalized body response.

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply.

-Serous drainage is composed of the clear portion of the blood and serous membranes. -Sanguineous drainage is composed of a large number of red blood cells and looks like blood. -Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. -Purulent drainage is composed of white blood cells, dead tissue, and bacteria.

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply.

-The patient is 86 years old. -The patient reports inability to control urine. -The patient is scheduled for a hip arthroplasty. -The patient reports increased pain in right hip when repositioning in bed or chair.

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure injury? Select all that apply.

-Use whirlpool treatments, if prescribed, until the ulcer is considered clean. -Keep the injury tissue moist and the surrounding skin dry. -Use a dressing that absorbs exudate but maintains a moist healing environment.

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

T/F A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

true

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

use pillows to maintain a side-lying position as needed