Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
foundation ch.32
| Question | Answer |
|---|---|
| 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? | removing dead or infected tissue to promote wound healing |
| Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? | preventing the client from sliding in bed |
| 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? | a sterile, flexible applicator moistened with saline |
| The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? | Document the color, odor, amount, and type of wound drainage. |
| For which client would the application of a hydrocolloid dressing be most appropriate? | A client who has a partial-thickness venous ulcer with moderate drainage |
| 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. |
| In the older adult client, wrinkling is related to: | loss of elasticity. |
| A full-thickness or third-degree burn develops a leathery covering called a(an): | eschar. |
| A client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues? | applying the dressing with a binder |
| The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding? | nonblanchable redness |
| When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? | Off-load pressure from the heel. |
| 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. |
| 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 |
| 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 sacral wound. Upon assessment, the wound is noted to be intact, reddened, and unblanchable. How will the nurse categorize this pressure injury? | stage I |
| 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 | a transparent film |
| 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 |
| The nurse is caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states, "My pain medication is effective, but will this pain ever get better and go away?" Which response is correct? | "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." |
| A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. T or F? | true |
| 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? | “Dehiscence is when a wound has partial or total separation of the wound layers.” |
| 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. |
| 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 comes to the emergency department after falling off a skateboard onto the sidewalk. Which assessment data, consistent with an abrasion, would the nurse expect to see? | scraping off of surface layers of skin |
| The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care | Increases the risk of infection by contaminating the wound |
| A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making? | The nurse should apply adhesive wound closure strips after removing staples. |
| A postoperative client says during a transfer, “I feel like something just popped.” The nurse immediately assesses for: | dehiscence |
| 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. |
| A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? | covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position using sterile technique |
| 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 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. |
| What is another term for localized dehydration in a wound? | Desiccation |
| A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. T or F? | True |
| A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? | Clean the wound from the top to the bottom and from the center to outside. |
| 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 |
| 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 II |
| 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 |
| The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action? | Recompress the drain before replacing the cap. |
| Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? | corticosteroids |
| 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 |
| 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?” |
| Which is not considered a skin appendage? | Connective tissue |
| 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 |
| The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. | “Very little scar tissue will form.” “This is a simple reparative process.” “Your wound edges are right next to each other.” |
| 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? | 105°F to 109°F (40.5°C to 43°C) |
| A postoperative client says during a transfer, “I feel like something just popped.” The nurse immediately assesses for: | dehiscence. |
| 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 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 |
| 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 |
| 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. |
| When applying an external heating pad, which prescription from the health care provider would the nurse question? | Leave heating pad on for 40 to 45 minutes, then off for 2 hours. |
| 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. |
| The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? | "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." |
| 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. |
| client is in a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement? | mechanical debridement |
| A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product? | The dressing allows oxygen exchange between the wound and environment. |
| The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? | Apply a skin protectant to the skin around the incision. |
| 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 |
| 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.” |
| The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? | "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." |
| 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. |
| The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? | an alginate dressing |
| The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day? | The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. |
| 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 |
| The nurse caring for a postoperative client is cleaning the client’s wound. Which nursing action reflects the proper procedure for wound care? | The nurse works outward from the wound in lines parallel to it. |
| The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? | Apply a skin protectant to the skin around the incision. |
Created by:
briannagrace