Skin Integrity and Wound Care

Skin Integrity and Wound Care 1. The nurse would recognize which client as being, particularly susceptible to impaired wound healing? a. An obese woman with a history of type 1 diabetes 2. 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 squeeze the chamber and apply the cap to maintain negative pressure.” 3. A nurse has applied a bandage to a client’s arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. a. Fingers with quick capillary refill b. Warm hand c. No finger numbness or tingling 4. 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? a. “I will put a layer of cloth between my skin and the ice pack.” 5. The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a. A surgical incision with sutures approximated edges 6. The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? a. “Very little scar tissue will form.” 7. A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain? a. The status of the client’s tetanus immunization 8. The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? a. Document the color, odor, amount, and type of wound drainage. 9. A client reports acute pain while negative pressure would therapy is in place. What should the nurse do first? a. Assess the client’s wound and vital signs 10. 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 currently? a. Discontinue the therapy and assess the client. 11. 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? a. Rotate the swab several times over the wound surface to obtain an adequate specimen. 12. The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse’s competence in providing wound care? Select all that apply. a. A nurse places transparent dressing over a central venous access device insertion site b. A nurse uses aseptic techniques when changing a dressing c. A nurse places a drainage dressing around a drain insertion site 13. 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 to facilitate rehydration. What type of dressing will the nurse apply over the client’s venous access site? a. A transparent film 14. 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? a. “Your wound will heal slowly as granulation tissue forms and fills the wound.” 15. A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? a. Black classification 16. A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? a. Clean the wound from top to the bottom and from the center to outside. 17. 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? a. Contusion 18. 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? a. Dehiscence of the wound 19. A nurse is removing a client’s surgical sutures. What is the correct order of steps? a. Clean the incision using the wound cleanser and gauze b. Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin c. Using the scissors, cut one side of the suture below the knot, close to the skin d. Grasp the knot with the forceps and pull the cut suture through the skin e. Remove every other suture to be sure the wound edges are haled f. Apply adhesive closure strips 20. 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? a. Use pillows to maintain a side-lying position as needed 21. 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? a. Removing dead or infected tissue to promote wound healing. 22. The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? a. Stage II 23. The nurse observes the presence of intestinal contents protruding from the client’s surgical wound after colon resection. What action will the nurse take? a. Apply saline solution-moistened gauze over the protruding area 24. A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? a. Foul-smelling drainage that is grayish in color. 25. The nurse is helping a confused client with a large leg wound to order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? a. Fish 26. 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 form shearing forces? a. A client sitting in a chair who slides down 27. 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? a. Evisceration 28. Upon review of a postoperative client’s medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a. Corticosteroids 29. The registered nurse (RN) observes the licensed practical nurse (LPN) performing this action when applying a topical gel to a client’s surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? a. “To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator.” 30. A client who had a knee replacement asks the nurse, “Why do I need this little bulb coming out of my knee?” What is the appropriate nursing response? a. “The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound.” 31. A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in the remodeling phase of wound repair. Which statement describes this phase of wound recovery? a. Period during which the wound undergoes changes in maturation 32. 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? a. Keep the swab and the inside of the culture tube sterile prior to collecting the culture. 33. The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? a. “Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer.” 34. 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? a. Stage IV 35. 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? a. Stage II 36. A client recovering from abdominal surgery sneezes and then screams, “My insides are hanging out!” What is the initial nursing intervention? a. Applying sterile dressings with normal saline over the protruding organs and tissue 37. 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? a. Desiccation 38. What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? a. To splint the area when engaging in activity 39. The nurse in the post anesthesia care unit (PACU) is assessing a new client who has just undergone abdominal exploratory laparotomy. Which response should the nurse prioritize after nothing the SaO2 is 95% (0.95), blood pressure is 128/80 mm Hg, cardiac monitor is showing rare premature atrial contractions (PAC), and drainage on abdominal dressing is approximately 5 cm x 3 cm of pinkish drainage along the lower edge of the dressing? a. Apply additional dressing, especially over the lower edge where drainage is occurring 40. 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? a. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis 41. The nurse and client are looking at the client’s heel pressure injury. The client asks, “why does my heel look black?” What is the appropriate response? a. “That is necrotic tissue, which must be removed to promote healing.” 42. The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad? a. 105 F to 109 F (40.5 C to 43 C) 43. The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client’s room? a. Transparent