Tissue Integrity

A nurse is caring for a 37-year-old male who had abdominal surgery 1 day ago. Upon examining the incision, the nurse notices a purulent exudate has formed around the incision site. Which component does a purulent exudate consist of? 1 Bacteria 2 Plasma 3 A mix of plasma and blood 4 Bright red blood

1 Bacteria Purulent drainage is usually thick and indicates bacterial infection. It can be yellow, greenish, or beige.

A patient is admitted with a stage II pressure ulcer. Which characteristics of a pressure ulcer is the nurse likely to find during a wound assessment? 1 It has a red-pink wound bed without slough. 2 The subcutaneous fat is visible. 3 It may include undermining and tunneling. 4 The wound extends to muscles and bones.

1 It has a red-pink wound bed without slough. A stage II pressure ulcer has a partial thickness loss of dermis and is shallow. It has a red-pink wound bed without slough.

A 56-year-old hemiplegic patient lives in a long-term care facility. On examination, the nurse notices a pressure injury on the skin over his sacrum. Which factors may influence the development of bed ulcers in this patient? Select all that apply. 1 Chronic immobility can cause pressure injuries. 2 Excessive moisture prevents pressure injuries. 3 Nutrition has no effect on pressure injury incidence. 4 Edema of the skin can cause pressure injuries. 5 Dehydration of the body can cause pressure injuries.

1, 4, 5 Many factors influence the formation of pressure injuries in this patient. A patient who is bedfast or chairfast, or who only walks occasionally, is at risk of developing pressure injuries. Exposure to excessive moisture, which can lead to edema, increases the risk of pressure injuries. Fluid imbalance increases the patient's risk for pressure injuries. Excessive moisture macerates the skin and increases the risk of developing pressure injuries. Decreased nutrition status is linked to pressure injury formation and poor wound healing.

A nurse works in a long-term care unit. Which patients would be at high risk of developing pressure ulcers? Select all that apply. 1 A patient with spinal cord injury 2 A comatose patient 3 A patient with urinary incontinence 4 An immobile patient with excessive wound drainage 5 A postoperative patient after a laparoscopic cholecystectomy

1,2,3,4 The patient who underwent laparoscopic cholecystectomy is active and not immobile. The patient is not at risk of developing pressure ulcers.

The patient has a stage III pressure ulcer. Which findings are characteristic of this type of pressure ulcer? Select all that apply. 1 It has full-thickness tissue loss. 2 The subcutaneous fat may be visible. 3 It may present as an open serum-filled blister. 4 It may have a red-pink wound bed without slough. 5 The bone, tendon, or muscle is not exposed.

1,2,5 Text Reference - p. 600 A stage III pressure ulcer has a full-thickness tissue loss involving epidermis and dermis. Due to this, the subcutaneous fat may be visible. However, the wound is not deep enough to expose the bone, tendon, or the muscle. A wound with an open serum-blister or having a red-pink wound bed with slough is a stage II pressure ulcer.

The nurse understands that the nutritional status of a patient is an important factor in wound healing. Which vitamins would be provided to the patient to promote wound healing? Select all that apply. 1 A 2 B 3 C 4 D 5 E

1,3

Order the phases of wound healing

1. Inflammation 2. proliferative 3. maturation

A long-term care facility encourages nurses to assess patients at risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the facility using for risk assessment of pressure ulcer development? 1 GNASC tool 2 Braden Scale 3 Bates-Jensen tool 4 WOCN scale

2 Braden Scale

A nurse is planning diet therapy for a patient with a wound. Which nutritional deficiencies may cause delayed wound healing? Select all that apply. 1 Fat 2 Zinc 3 Copper 4 Vitamin C 5 Magnesium

2,3,4 Proper nutrition is very important for normal wound healing. Zinc, copper, and vitamin C promote wound healing. Fat and magnesium do not play major roles in wound healing.STUDY TIP: Collagen formation is part of wound healing, so think "C" for wound healing: zinC, Copper, and vitamin C.

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. Which stage best defines this patient's pressure ulcer? 1 Stage II 2 Stage IV 3 Unstageable 4 Suspected deep tissue damage

3 Unstageable Text Reference - p. 600

A nurse is teaching student nurses about the inflammatory response to an injury. Arrange the events in the order of their occurrence in a response to injury. 1. Formation of granulation tissue 2. Formation of exudate at site of injury 3. Rapid vasodilation at site of injury 4. Accumulation of fluid at site of injury

3,4,2,1 Text Reference - p. 594

A nurse is caring for a group of patients with wounds that are healing by primary intention. The nurse is attending to which types of wounds? Select all that apply. 1 Pressure ulcer 2 Chronic wound 3 Surgical incision 4 Full-thickness wound 5 Traumatic approximated wound

3,5 Text Reference - p. 594

This drainage usually indicates bleeding and is bright red

Sanguinous drainage

this drainage is pink to pale red and contains a mix of serous fluid and red, bloody fluid.

Serosanguinous drainage

bacterial infection of the subcutaneous tissue and the dermis; occurs most commonly in lower extremities, buccal, and preiorbital areas; most frequent in children 2 years and younger

cellulitis

partial or complete separation of the tissue layers during the healing process; usually occurs in connection with surgical incisions

dehiscence

the total separation of the tissue layers, allowing the protrusion of visceral organs through the incision

evisceration

wound that extends through the dermis to the subcutaneous layer and may extend farther, to the muscle, bone, or other underlying structures

full thickness wound

body's initial response to wounding of the skin that lasts about 3 days

inflammatory phase

last phase of wound healing; callogen continues to be deposited and scar tissue forms

maturation phase

a wound that involves the epidermis and the dermis, but does not extend through the dermis to the subcutaneous layer

partial thickness wound

phase in wound healing that repairs the defecit; fills the wound bed with new tissue, called granulation tissue; and resurfaces the wound with skin

proliferative phase

drainage contains clear, watery fluid from plasma.

serous drainage

a wound that involves only the epidermis

superficial wound