Ch. 32 Skin Integrity & Wound Care Flashcards
A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for
impaired wound healing? (Select all that apply.)
A. Extremes in age
B. Chronic illness
C. Low hemoglobin
D. Malnutrition
E. Poor wound care
B. CORRECT: Diabetes mellitus is a chronic illness that places additional stress on the body’s healing mechanisms.
C. CORRECT: Hgb is essential for oxygen delivery to healing tissues, and this client’s Hgb level is low.
D. CORRECT: A BMI of 17.1 indicates that the client is underweight and, therefore, malnourished. Deficiencies
in essential nutrients delay wound healing.
A nurse is collecting data from a client who is 5 days
postoperative following abdominal surgery. The
surgeon suspects an incisional wound infection and
has prescribed antibiotic therapy for the nurse to
initiate after collecting wound and blood specimens for
culture and sensitivity. Which of the following findings
should the nurse expect? (Select all that apply.)
A. Increase in incisional pain
B. Fever and chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
E. Decrease in thirst
A. CORRECT: Expect the client to have pain and tenderness
at the wound site with an incisional infection.
B. CORRECT: Expect the client to have fever
and chills with an incisional infection.
C. CORRECT: Expect the client to have reddened or
inflamed wound edges with an incisional infection
A nurse educator is reviewing the wound healing
process with a group of nurses. The nurse
educator should include in the information which
of the following alterations for wound healing by
secondary intention? (Select all that apply.)
A. Stage 3 pressure injury
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed with adhesive
E. Open burn area
A. CORRECT: Open pressure ulcers heal by secondary
intention, which is the process for wounds that have
tissue loss and widely separated edges.
E. CORRECT: Open burn areas heal by secondary
intention, which is the process for wounds that have
tissue loss and widely separated edges
A client who had abdominal surgery 24 hr ago
suddenly reports a pulling sensation and pain
in their surgical incision. The nurse checks the
surgical wound and finds it separated with
viscera protruding. Which of the following actions
should the nurse take? (Select all that apply.)
A. Cover the area with saline‑soaked sterile dressings.
B. Apply an abdominal binder snugly
around the abdomen.
C. Use sterile gauze to apply gentle
pressure to the exposed tissues.
D. Position the client supine with
the hips and knees bent.
E. Offer the client a warm beverage (herbal tea).
A. CORRECT: Cover the wound with a sterile dressing
soaked with sterile normal saline solution to keep
the exposed organs and tissues moist until the
surgeon can assess and intervene.
D. CORRECT: This position minimizes
pressure on the abdominal area.
A nurse is caring for a client who is at risk for
developing pressure injury. Which of the following
interventions should the nurse use to help maintain
the integrity of the client’s skin? (Select all that apply.)
A. Keep the head of the bed elevated 30°.
B. Massage the client’s bony prominences frequently.
C. Apply cornstarch liberally to the skin after bathing.
D. Have the client sit on a gel cushion when in a chair.
E. Reposition the client at least
every 3 hr while in bed.
A. CORRECT: Slightly elevate the head of the client’s
bed to reduce shearing forces that could tear sensitive
skin on the sacrum, buttocks, and heels.
D. CORRECT: Have the client sit on a gel, air, or foam cushion
to redistribute weight away from ischial areas
A nurse is providing information about a new
prescription for corticosteroid cream to a client who
has mild psoriasis. Which of the following instructions
should the nurse include? (Select all that apply.)
A. Apply an occlusive dressing after application.
B. Apply three to four times per day.
C. Wear gloves after application
to lesions on the hands.
D. Avoid applying in skin folds.
E. Use medication continuously over
a period of several months.
A. CORRECT: An occlusive dressing can enhance the efficacy
of the topical corticosteroid on the exposed lesions.
C. CORRECT: Gloves worn after the medication can
enhance the efficacy of the topical corticosteroid
on the exposed lesions of the hands.
D. CORRECT: Corticosteroid cream applied to lesions in
skin folds increases the risk of yeast infections
A nurse is teaching a client who has a history of
psoriasis about photochemotherapy and ultraviolet
light (PUVA) treatments. Which of the following
instructions should the nurse include in the teaching?
A. Apply vitamin A cream before each treatment.
B. Administer a psoralen medication
before the treatment.
C. Use this treatment every evening.
D. Remove the scales gently following each treatment
B. CORRECT: PUVA treatment involves the administration of
a medication (psoralen) to enhance photosensitivity
A nurse is educating a client on the use of
calcipotriene topical medication for the
treatment of psoriasis. Which of the following
laboratory values should the nurse monitor?
A. Potassium
B. Calcium
C. Sodium
D. Chloride
B. CORRECT: Hypercalcemia is a possible
adverse effect of calcipotriene
A nurse is providing teaching to the guardian of
a child who has contact dermatitis. Which of the
following information should the nurse include?
A. Use fabric softener dryer sheets when
drying the child’s clothing.
B. Apply a warm, dry compress to the rash area.
C. Place the child in a bath with colloidal oatmeal.
D. Leave the child’s hands uncovered during the night.
C. CORRECT: The use of a colloidal oatmeal
bath will relieve the child’s itching
A nurse caring for a client who has contact
dermatitis and has a new prescription for
diphenhydramine. For which of the following
adverse effects should the nurse monitor?
A. Elevated blood glucose levels
B. Anorexia
C. Increased salivation
D. Insomnia
B. CORRECT: Monitor the client for anorexia, which is
a possible adverse effect of diphenhydramine
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. Administer antipyretics, as prescribed. Increase the frequency of assessment to every hour and notify the patient’s primary care provider. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.
a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.
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. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. Serosanguineous drainage can be dark yellow or green depending on the causative organism.
a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.
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.
Notify the health care provider of the situation. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. Place the patient in the low Fowler’s position.
c, b, a. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler’s position (to prevent further physical damage), cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). Note that the interprofessional team may be completing the activities simultaneously in the clinical setting, but the priority identified above is important to understand.
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?
Pain Impaired Skin Integrity Disturbed Body Image Disturbed Thought Processes
c. Wounds cause emotional as well as physical stress.
A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?
Using sterile dressing supplies Suggesting dietary supplements Applying antibiotic ointment Performing careful hand hygiene
d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.
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. A liquid called exudate is formed during the proliferation phase. White blood cells move to the wound in the inflammatory phase. Granulation tissue forms in the inflammatory phase. During the inflammatory phase, the patient has generalized body response. A scar forms during the proliferation phase.
a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.
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.
Enhanced healing due to the presence of sugars and proteins Delayed healing due to dead tissue present in the wound Decreased effectiveness of antibiotics against the bacteria Impaired skin integrity due to overhydration of the cells of the wound Delayed healing due to cells dehydrating and dying Decreased effectiveness of the patient’s normal immune process
c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2016; Hess, 2013). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.
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 the wound in full or half circles beginning on the outside and working toward the center. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. Clean to at least 1 in beyond the end of the new dressing if one is being applied. Clean to at least 3 in beyond the wound if a new dressing is not being applied.
a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 in beyond the end of the new dressing, and (6) clean to at least 2 in beyond the wound margins if a dressing is not being applied.
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 takes time to think about responses to questions. The patient is 86 years old. The patient reports inability to control urine. The patient is scheduled for a hip arthroplasty. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). The patient reports increased pain in right hip when repositioning in bed or chair.
b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure injury development. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.
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 can expect to have more discomfort in the area where the cold is applied.” “I should expect more drainage from the incision after the ice has been in place.” “I should see less swelling and redness with the cold treatment.” “My incision may bleed more when the ice is first applied.”
c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.
A client has been hospitalized for 10 days in the intensive care unit on the ventilator and has been NPO. The nurse is giving the client a bath and notices skin breakdown on the sacrum exposing the dermis. When documenting in the medical record, what stage pressure injury will the nurse record?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
B) Stage 2
A pressure injury is skin damage usually over a bony prominence or from a medical device such as a Foley catheter tubing. A stage 2 pressure injury is skin damage through two layers of skin, the epidermis and the dermis. A stage 2 pressure injury is open, red, and moist extending to the dermis of the skin. Risk factors for pressure injuries include poor nutrition-being NPO for 3-5 days, dehydration, low albumin, chemotherapy, steroids, immobility, contractures, past history of pressure injuries, incontinence, diabetes, poor sensory perception, paralysis, and obesity. The Braden Scale is utilized to identify clients at high risk for pressure injuries. The Braden Scale rates clients by sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
The nurse is teaching a class on strategies of pressure injury prevention. What should be included in the information? Select all that apply.
A) Pressure redistribution every 1-2 hours
B) Use strong deodorant soaps when bathing
C) Encourage a diet high in protein and calories
D) Keep clients clean and dry by managing incontinence
E) Rub and massage pressure injuries
F) Use moisturizers and creams after bathing
A) Pressure redistribution every 1-2 hours
C) Encourage a diet high in protein and calories
D) Keep clients clean and dry by managing incontinence
F) Use moisturizers and creams after bathing
A nurse is assessing a sacral pressure injury on a client and evaluates that the wound base has yellow stringy slough noted. How should the nurse document this assessment?
A) Stage 1
B) Stage 2
C) Unstageable
D) Deep tissue injury
C) Unstageable
An unstageable pressure injury involves full thickness tissue damage but the wound base of the injury is obscured with yellow, brown, green, tan, or gray stringy slough or tan, black, or brown eschar. Once the slough is removed, the tissue damage will likely be a stage 3 or 4 pressure injury. An unstageable pressure injury is a full-thickness injury where the base of the wound is obscured by extensive slough or necrotic tissue. Debridement must be completed before staging can be performed. Treatment involves sharp, autolytic, enzymatic, or mechanical debridement of the slough or necrotic tissue, offloading the pressure, and adequate nutrition.
An 89-year-old client had right hip surgery a week ago. The rehab nurse assesses a purple maroon-colored blood-filled blistered area to the client’s right heel. How should the nurse document her findings?
A) Deep tissue injury
B) Stage 1
C) Stage 2
D) Stage 3
A) Deep tissue injury
A deep tissue injury involves tissue loss to the muscle and appears as a maroon, purple or red injury that may be a blood-filled blister or bulla. The tissue damage may not be visible at first, but the tissue damage is extensive and involves bone, tendon, and ligament. The injury usually appears between 24-48 hours after the damage has occurred. Treatment involves pressure relief strategies, adequate nutrition, such as increased protein and calories, and keeping the injury clean and dry until the blister bursts. If the blister bursts, moist wound healing, pressure relief, and increased protein and calories are required to heal the injury. With any pressure injury, the nurse should avoid massaging the bony prominences.
