Chapter 32- Skin Integrity and Wound Care Prep U Questions.docx
1. A pediatric nurse is familiar with specific characteristics of children's skin.
... [Show More] Which statement describes the common skin characteristics in a child?
2. 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?
3. Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?
4. A nurse is caring for a client who has recently undergone repair of a ventral hernia. What situations should the nurse assess for that may increase the risk for delay in surgical wound healing? Select all that apply.
5. 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?
6. 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?
7. A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
8. A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
9. 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?
10. 1The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?
11. The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?
Explanation:
The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client’s neck. The nurse would not cover the heating pad with a heavy blanket.
12. 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
Explanation:
Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down.
The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.
13. 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
Explanation:
Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing.
However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.
14. Which is not considered a skin appendage?
• Connective tissue
Explanation:
Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.
15. 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.
Explanation:
Local capillary pressure must be higher than external pressure for adequate skin perfusion.
16. 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
Explanation:
An incision is a clean separation of skin and tissue with smooth, even edges. Therefore the nurse documents the finding as an incision. In an avulsion, large areas of skin and underlying tissue have been stripped away. An abrasion involves the stripping of the surface layers of skin. A laceration is a separation of skin and tissue with torn, irregular edges. Therefore the nurse does not document the finding as an avulsion, abrasion, or laceration.
17. 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.”
Explanation:
After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples. Reinforced adhesive skin closures are not strong enough to hold this type of wound together.
18. 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.”
Explanation:
Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.
19. 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.”
Explanation:
The bulb-like drain allows removal of blood and drainage from the surgical site. It does not provide a route for medication administration or decrease the chance for infection, nor does it stay attached permanently.
20. 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.
Explanation:
The best response by the nurse is to explain the possible complications of leaving cold therapy in place for too long, including cell death and tissue necrosis. This response not only answers the client’s question but teaches at the same time the rationale and reason for limiting the cold therapy. Leaving the therapy on for 10 more minutes places the client at increased risk of tissue injury. Assisting the client out of bed ignores the client’s request. Using the health care provider’s prescription as the reason displays lack of understanding by the nurse and does not aid the client in understanding the rationale for the time limit.
1. The nurse would recognize which client as being particularly susceptible to impaired wound healing?
• an obese woman with a history of type 1 diabetes
Explanation:
Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.
2. An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:
• milia.
Explanation:
Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.
3. A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:
• a rash related to a yeast infection.
Explanation:
Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.
4. 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.
Explanation:
If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.
5. 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
Explanation:
Partial-thickness burns may be superficial or moderate to deep. A superficial partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good
example. Moderate to deep partial-thickness burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present.
The full-thickness burn appears dry and leathery.
6. A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?
• A Penrose drain promotes passive drainage into a dressing.
Explanation:
A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.
7. 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
Explanation:
The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.
8. 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?”
Explanation:
The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of
lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.
9. A client’s risk for the development of a pressure injury is most likely due to which lab result?
• albumin 2.5 mg/dL
Explanation:
An albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury. A hemoglobin A1C level greater than 8% puts the client at risk for the development of pressure injuries due to a prolonged high glucose level. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not put the client at risk for the development of a pressure injuries.
10. The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?
• The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.
Explanation:
A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.
11. 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
Explanation:
Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.
12. 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
Explanation:
Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.
13. The nurse and client are looking at a client’s heel pressure injury. The client asks, “Why is there a small part of this wound that is dry and brown?” What is the nurse’s appropriate response?
• “Necrotic tissue is devitalized tissue that must be removed to promote healing.”
Explanation:
The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.
14. 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?
• transparent
Explanation:
Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist.
15. 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 nurse’s appropriate response?
• “That is necrotic tissue, which must be removed to promote healing.”
Explanation:
Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.
16. The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?
• figure-of-eight turn
Explanation:
A figure-of-eight turn is used for joints like the elbows and knees. The other answers are incorrect.
17. 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
Explanation:
Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.
18. 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.
Explanation:
The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.
19. 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
Explanation:
If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.
20. What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson–Pratt drain?
• Secure the drain to the client’s gown with a safety pin below the level of the wound.
Explanation:
To ensure there is not any tension on the tubing of a Jackson–Pratt drain, the nurse should secure the drain to the client’s gown with a safety pin below the level of the wound. Taping the drain or applying an abdominal binder will keep the bulb compressed and hinder the suction action of the drain. The drain should not be allowed to hang freely because this causes tension on the drain site.
1. Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
• corticosteroids
Explanation:
Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.
2. Which action should the nurse perform when applying negative pressure wound therapy?
• 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.
3. 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
Explanation:
Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are
obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that “something has suddenly given way.” If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician.
Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.
4. 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
Explanation:
Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.
5. A nurse is caring for a client with a nonhealing stage IV pressure injury. 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?
• 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; it 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.
6. 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.
Explanation:
The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.
7. 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
Explanation:
To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.
8. 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
Explanation:
Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.
9. 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
Explanation:
This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.
10. 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.
Explanation:
First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client’s vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed. [Show Less]