Wound Healing – Flashcards
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A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? A. Take the antibiotic until the wound feels better. B. Take the analgesic every day to promote adequate rest for healing. C. Be sure to wash hands after changing the dressing to avoid infection. D. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. E. Notify the health care provider of redness, swelling, and increased drainage.
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C, D. Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing.
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A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? A. Increased platelet count B. Increased blood urea nitrogen C. Increased number of band neutrophils. D. Increased number of segmented myelocytes
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C. Increased number of band neutrophils. The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.
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A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? A. Serous B. Purulent. C. Fibrinous D. Catarrhal
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B. Purulent. Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.
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A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? A. Frequent examination of the character and quantity of exudate B. Monitoring for signs and symptoms of local or systemic infections. C. Assessment of the patient's circulation distal to the location of the dressing. D. Assessment of the range of motion of the ankle and the patient's activity tolerance
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C. Assessment of the patient's circulation distal to the location of the dressing. Any compression dressing requires vigilant assessment of the circulation distal to the dressing site because tissue and nerve damage is a significant risk. This supersedes the importance of assessing the patient's mobility. Exudate and infection would not normally accompany a soft tissue injury such as a sprain.
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A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? A. Pain level B. Intake and output C. Oxygen saturation D. Level of consciousness
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B. Intake and output Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient.
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A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? A. Adhesion B. Contractions C. Keloid formation D. Excess granulation tissue
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D. Excess granulation tissue Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable.
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A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? A. Warm, moist heat and massage B. Rest, ice, compression, and elevation C. Antipyretic and antibiotic drug therapy D. Active movement and exercise to prevent stiffness
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B. Rest, ice, compression, and elevation Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation. Heat may be applied 24 to 48 hours after the injury.
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A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? A. Administer aspirin on a scheduled basis around the clock. B. Provide acetaminophen every 4 hours to maintain consistent blood levels. C. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. D. Provide drug interventions if complementary and alternative therapies have failed.
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B. Provide acetaminophen every 4 hours to maintain consistent blood levels. Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.
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A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? A. Apple B. Custard C. Popsicle D. Potato chips
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B. Custard Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. The other snacks do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid that are also needed for healing.
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After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? A. Reposition every 2 hours. B. Measure the size of the reddened area. C. Massage the area to increase blood flow. D. Evaluate the area later to see if it is better.
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A. Reposition every 2 hours. The most important thing to do for this patient is to prevent deterioration of the ulcer and eliminate factors that led to pressure ulcers. This would include eliminating pressure on the reddened area with repositioning every 2 hours in bed and every hour while up in the chair. The nurse must complete the assessment of the new reddened area as well as evaluation of the area. Massage is not used when there is the possibility of damaged blood vessels or fragile skin, so the RN cannot advise the UAP to do this until the RN has assessed the patient and the area.
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An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? A. Dress it with an absorbent dressing for exudate. B. Handle the wound gently and let it dry out to heal. C. Debride the nonviable, eschar tissue to allow healing. D. Use negative-pressure wound (vacuum) therapy to facilitate healing.
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C. Debride the nonviable, eschar tissue to allow healing. With a black wound, the immediate therapy should be debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first. The red wound is handled gently because it is granulating and re-epithelializing, but it must be kept slightly moist to heal. The negative-pressure wound (vacuum) therapy is used to remove drainage and is more likely to be used after debridement.
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The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? A. Fever and chills B. Increased blood pressure C. Increased respiratory rate D. General malaise and fatigue
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D. General malaise and fatigue An immunosuppressed individual may have the classic symptoms of inflammation or infection masked by the inability to launch a normal immune response. Therefore, in this person, early symptoms may be malaise, fatigue, or "just not feeling well."
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The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? A. The wound will be stapled together until it heals. B. The healing will contract the area to close the wound. C. The wound will be left open and heal from the edges inward. D. The wound will be sutured after the current infection is controlled.
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C. The wound will be left open and heal from the edges inward. With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled.
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The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse? A. Provide a light blanket. B. Encourage a hot shower. C. Monitor temperature every hour. D. Turn up the thermostat in the patient's room.
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A. Provide a light blanket. Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.
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The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? A. Local response. B. Systemic response. C. Infectious response. D. Acute inflammatory response.
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B. Systemic response. The systemic response to inflammation includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in 2 to 3 weeks and usually leaves no residual damage.
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The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? A. Notify the health care provider. B. Document the fistula formation. C. Assess the patient and vaginal drainage. D. Have the UAP apply a dressing to the vagina.
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C. Assess the patient and vaginal drainage. With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse should first assess the patient and drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care provided, describe interventions prescribed, and document the care and patient response.
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To which patient should the nurse plan to administer round-the-clock antipyretic drugs? A. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F B. An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F C. A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F D. A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F
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A. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F Moderate fevers (up to 103°F) usually produce few problems in most patients and do not require antipyretic therapy. If the patient is very young or very old, is extremely uncomfortable, or has a significant medical problem (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. High fevers (above 104°F) should be treated with antipyretics. High fevers can damage body cells and cause delirium and seizures.
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When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? A. White blood cell (WBC) count of 8000/ìL; temperature of 101?5? F B. White blood cell (WBC) count of 4000/ìL; temperature of 100?5? F C. White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F D. White blood cell (WBC) count of 16,500/ìL; temperature of 98.8?5? F
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C. White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/ìL. An elevated WBC count and elevated temperature are indicators of infection.
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Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? A. Keep the pressure ulcer clean and dry. B. Maintain protein intake of at least 1.25 g/kg/day. C. Use a 10-mL syringe to irrigate the pressure ulcer. D. Irrigate the pressure ulcer with hydrogen peroxide.
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B. Maintain protein intake of at least 1.25 g/kg/day. Adequate protein intake (between 1.25 and 1.50 g/kg/day) is needed to promote healing of pressure ulcers. Hydrogen peroxide is cytotoxic and should not be used to clean pressure ulcers. A 30-mL syringe with a 19-gauge needle will provide optimal pressure (4 to 15 psi) without causing tissue trauma or damage. The pressure ulcer should be kept moist to aid in healing.
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Which patient is most at risk for the development of a pressure ulcer? A. An older patient who is septic, bedridden, and incontinent. B. An obese woman with leukemia who is receiving chemotherapy. C. A middle-aged thin man in a halo cast after a motor vehicle accident. D. An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis
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A. An older patient who is septic, bedridden, and incontinent. Individuals at risk for the development of pressure ulcers include those who are older, incontinent, bed or wheelchair bound, or recovering from spinal cord injuries. Other examples of risk factors include diabetes mellitus, elevated body temperature, immobility, and anemia.
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The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development? A. Decreased level of consciousness B. Adequate dietary intake C. Shortness of breath D. Muscular pain
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A. Decreased level of consciousness Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and an adequate dietary intake are not included among the predisposing factors.
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The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer? A. Resistance B. Pressure C. Weight D. Stress
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B. Pressure Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers.
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Which nursing observation will indicate the patient is at risk for pressure ulcer formation? A. The patient has fecal incontinence. B. The patient ate two thirds of breakfast. C. The patient has a raised red rash on the right shin. D. The patient's capillary refill is less than 2 seconds.
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A. The patient has fecal incontinence. The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.
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The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record? A. Stage I pressure ulcer B. Healing Stage II pressure ulcer C. Healing Stage III pressure ulcer D. Stage III pressure ulcer
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C. Healing Stage III pressure ulcer When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words "healing stage" or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage III, and it cannot return to a previous stage such as Stage I or II. This ulcer is healing, so it is no longer labeled a Stage III.
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The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV
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B. Stage II This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.
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The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient? A. Disposable measuring tape B. Cotton-tipped applicator C. Sterile gloves D. Halogen light
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D. Halogen light When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the entire assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items are not the first items used.
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The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? A. Partial-thickness wound repair B. Full-thickness wound repair C. Primary intention D. Tertiary intention
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B. Full-thickness wound repair Stage IV pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has four phases: hemostasis, inflammatory, proliferative, and maturation. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until risk of infection is resolved.
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The nurse is caring for a group of patients. Which patient will the nurse see first? A. A patient with a Stage IV pressure ulcer B. A patient with a Braden Scale score of 18 C. A patient with appendicitis using a heating pad D. A patient with an incision that is approximated
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C. A patient with appendicitis using a heating pad The nurse should see the patient with an appendicitis first. Warm applications are contraindicated when the patient has an acute, localized inflammation such as appendicitis because the heat could cause the appendix to rupture. Although a Stage IV pressure ulcer is deep, it is not as critical as the appendicitis patient. The total Braden score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development. A score of 18 can be assessed later. A healing incision is approximated (closed); this is a normal finding and does not need to be seen first.
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The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing? A. Eschar B. Slough C. Granulation D. Purulent drainage
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C. Granulation Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.
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The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? A. Partial-thickness repair B. Secondary intention C. Tertiary intention D. Primary intention
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D. Primary intention A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.
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The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient? A. Partial-thickness repair B. Secondary intention C. Tertiary intention D. Primary intention
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B. Secondary intention A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repair is done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved.
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A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention? A. Minimal loss of tissue function B. Permanent dark redness at site C. Minimal scar tissue D. Scarring that may be severe
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D. Scarring that may be severe A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.
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The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing? A. The site is hurting. B. The site is approximated. C. The site has started to itch. D. The site has a mass, bluish in color.
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D. The site has a mass, bluish in color. A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching is not a complication. Incisions should be approximated with edges together; this is a sign of normal healing. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient will experience pain.
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A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? A. Protrusion of visceral organs through a wound opening B. Chronic drainage of fluid through the incision site C. Report by patient that something has given way D. Drainage that is odorous and purulent
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C. Report by patient that something has given way Patients often report feeling as though something has given way with dehiscence. Dehiscence occurs when an incision fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Evisceration is seen when vital organs protrude through a wound opening. When there is an increase in serosanguineous drainage from a wound in the first few days after surgery, be alert for the potential for dehiscence. Infection is characterized by drainage that is odorous and purulent.
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A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? A. Vitamin E B. Potassium C. Albumin D. Sodium
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C. Albumin Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested but also what the body has absorbed, digested, and metabolized. Zinc and copper are the minerals important for wound healing, not potassium and sodium. Vitamins A and C are important for wound healing, not vitamin E.
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A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? A. Muscular strength assessment B. Pulse oximetry assessment C. Sensation assessment D. Sleep assessment
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B. Pulse oximetry assessment Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.
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The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? A. Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results. B. Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR). C. Consult the wound care nurse about the change in status and the potential for infection. D. Check with the charge nurse about the change in status and the potential for infection.
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A. Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results. The patient is showing signs and symptoms associated with infection in the wound. The nurse should complete the assessment: gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the primary care provider and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.
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The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian? A. Fat B. Protein C. Vitamin E D. Carbohydrate
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B. Protein Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E will not be increased for wound healing.
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The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept? A. "I am so weak and tired. I want to feel better." B. "I am thinking I will be ready to go home early next week." C. "I am ready for my bath and linen change right now since this is awful." D. "I am hoping there will be something good for dinner tonight."
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C. "I am ready for my bath and linen change right now since this is awful." Body image changes can influence self-concept. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens and states that this is awful gives you a clue that he or she may be concerned about the smell in the room. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The patient's stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.
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A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take? A. Inspect the wound for foreign bodies. B. Inspect the wound for bleeding. C. Determine the size of the wound. D. Determine the need for a tetanus antitoxin injection.
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B. Inspect the wound for bleeding. After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.
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The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? A. Provide analgesic medications as ordered. B. Avoid accidentally removing the drain. C. Don sterile gloves. D. Gather supplies.
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A. Provide analgesic medications as ordered. Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure.
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The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take next? A. Call the health care provider; a blockage is present in the tubing. B. Chart the results on the intake and output flow sheet. C. Do nothing, as long as the evacuator is compressed. D. Remove the drain; a drain is no longer needed.
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A. Call the health care provider; a blockage is present in the tubing. Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the health care provider. The health care provider, not the nurse, determines the need for drain removal and removes drains. Charting the results on the intake and output flow sheet does not take care of the problem. The evacuator may be compressed even when a blockage is present.
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The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient? A. Low-air-loss B. Air-fluidized C. Lateral rotation D. Standard mattress
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B. Air-fluidized For a patient with newly flapped or grafted surgical sites, the air-fluidized bed will be the best choice; this uses air and fluid support to provide pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment. A low-air-loss bed is utilized for prevention or treatment of skin breakdown by preventing buildup of moisture and skin breakdown through the use of airflow. A standard mattress is utilized for an individual who does not have actual or potential altered or impaired skin integrity. Lateral rotation is used for treatment and prevention of pulmonary, venous stasis and urinary complications associated with mobility.
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The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate? A. Monitor the wound. B. Document the wound. C. Debride the wound. D. Manage drainage from wound.
answer
C. Debride the wound. Debridement is the removal of nonviable necrotic (black) tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Documentation occurs after completion of skill. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean, but that is not the next step.
question
The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question? A. Use a low-air-loss therapy unit. B. Irrigate with Dakin's solution. C. Apply a hydrogel dressing. D. Consult a dietitian.
answer
B. Irrigate with Dakin's solution. Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.
question
The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority? A. Pressure points B. Breath sounds C. Bowel sounds D. Pulse points
answer
A. Pressure points Observe pressure points such as bony prominences. The nurse continually assesses the skin for signs of ulcer development. Assessment for tissue pressure damage includes visual and tactile inspection of the skin. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part or priority of a skin assessment.
question
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient? A. 15 B. 17 C. 20 D. 23
answer
C. 20 With use of the Braden Scale, the total score is a 20. The patient receives 3 for slight sensory perception impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear.
question
The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility? A. Explain the risks of immobility to the patient. B. Turn the patient every 3 hours while in bed. C. Encourage the patient to sit up in the chair. D. Provide analgesic medication as ordered.
answer
D. Provide analgesic medication as ordered. Maintaining adequate pain control (providing analgesic medications) and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. Although sitting in the chair is beneficial, it does not increase mobility or provide pain control. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours and, again, does not influence the patient's ability to increase mobility.
question
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan? A. Readiness for enhanced nutrition B. Impaired physical mobility C. Impaired skin integrity D. Chronic pain
answer
C. Impaired skin integrity After the assessment is completed and the information that the patient has a Stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain do not support the current data in the question.
question
The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? A. Imbalanced nutrition: less than body requirements B. Ineffective peripheral tissue perfusion C. Risk for infection D. Acute pain
answer
B. Ineffective peripheral tissue perfusion The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective peripheral tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition do not support the data in the question.
question
The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first? A. Offer favorite fluids. B. Turn the patient every 2 hours. C. Determine the patient's risk factors. D. Encourage increased quantities of carbohydrates and fats.
answer
C. Determine the patient's risk factors. The first step in prevention is to assess the patient's risk factors for pressure ulcer development. When a patient is immobile, the major risk to the skin is the formation of pressure ulcers. Nursing interventions focus on prevention. Offering favorite fluids, turning, and increasing carbohydrates and fats are not the first steps. Determining risk factors is first so interventions can be implemented to reduce or eliminate those risk factors.
question
The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. Which health care team member will the nurse consult? A. Respiratory therapist B. Registered dietitian C. Case manager D. Chaplain
answer
B. Registered dietitian Refer patients with pressure ulcers to the dietitian for early intervention for nutritional problems. Adequate calories, protein, vitamins, and minerals promote wound healing for the impaired skin integrity. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can be consulted when the patient has a discharge need. A chaplain can be consulted when the patient has a spiritual need.
question
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient? A. The patient will state what to look for with regard to an infection. B. The patient's family will demonstrate specific care of the wound site. C. The patient's family members will wash their hands when visiting the patient. D. The patient will remain free of odorous or purulent drainage from the wound.
answer
D. The patient will remain free of odorous or purulent drainage from the wound. Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are not goals or outcomes for this nursing diagnosis.
question
The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel? A. Assessing a surgical patient for risk of pressure ulcers B. Applying an elastic bandage to a medical-surgical patient C. Treating a pressure ulcer on the buttocks of a medical patient D. Implementing negative-pressure wound therapy on a stable patient
answer
B. Applying an elastic bandage to a medical-surgical patient Applying an elastic bandage to a medical-surgical patient can be delegated to the nursing assistive personnel (NAP). Assessing pressure ulcer risk, treating a pressure ulcer, and implementing negative-pressure wound therapy cannot be delegated to an NAP.
question
The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one? 1. Apply sterile gloves. 2. Cover and secure topper dressing. 3. Assess wound and surrounding skin. 4. Moisten gauze with prescribed solution. 5. Gently wring out excess solution and unfold. 6. Loosely pack until all wound surfaces are in contact with gauze. A. 4, 3, 1, 5, 6, 2 B. 1, 3, 4, 5, 6, 2 C. 4, 1, 3, 5, 6, 2 D. 1, 4, 3, 5, 6, 2
answer
B. 1, 3, 4, 5, 6, 2 The steps for a moist-to-dry dressing are as follows: (1) Apply sterile gloves; (2) assess appearance of surrounding skin; (3) moisten gauze with prescribed solution. (4) Gently wring out excess solution and unfold; apply gauze as single layer directly onto wound surface. (5) If wound is deep, gently pack dressing into wound base by hand until all wound surfaces are in contact with gauze; (6) cover with sterile dry gauze and secure topper dressing.
question
The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk? A. Use gentle cleansers, and thoroughly dry the skin. B. Use therapeutic bed and mattress. C. Use absorbent pads and garments. D. Use products that hold moisture to the skin.
answer
A. Use gentle cleansers, and thoroughly dry the skin. Use cleansers with nonionic surfactants that are gentle to the skin. After you clean the skin, make sure that it is completely dry. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown. Use only products that wick moisture away from the patient's skin.
question
The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? A. At least 3 hours B. Less than 2 hours C. No longer than 30 minutes D. As long as the patient remains comfortable
answer
B. Less than 2 hours When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Sitting for longer than 2 hours can increase the chance of ischemia.
question
The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient? A. Place the patient in a 30-degree supine position. B. Utilize a transfer device to lift the patient. C. Elevate the head of the bed 45 degrees. D. Slide the patient into the new position.
answer
B. Utilize a transfer device to lift the patient. When repositioning the patient, obtain assistance and utilize a transfer device to lift rather than drag the patient. Sliding the patient into the new position will increase friction. The patient should be placed in a 30-degree lateral position, not a supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.
question
A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care? A. A patient with a clean Stage I B. A patient with a clean Stage II C. A patient with a clean Stage III D. A patient with a clean Stage IV
answer
A. A patient with a clean Stage I Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. A composite film, hydrocolloid, or hydrogel can be utilized on a clean Stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage III. Hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage IV. An unstageable wound covered with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes.
question
The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take? A. Turn on the television. B. Explain the procedure. C. Tell the patient "Close your eyes." D. Ask the family to leave the room.
answer
B. Explain the procedure. Explaining the procedure educates the patient regarding the dressing change and involves him in the care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close the eyes and turning on the television are distractions that do not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient's anxiety.
question
The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included? A. Allow the solution to flow from the most contaminated to the least contaminated. B. Scrub vigorously when applying noncytotoxic solution to the skin. C. Cleanse in a direction from the least contaminated area. D. Utilize clean gauze and clean gloves to cleanse a site.
answer
C. Cleanse in a direction from the least contaminated area. Cleanse in a direction from the least contaminated area, such as from the wound or incision, to the surrounding skin. While cleansing surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or by irrigations is correct, vigorous scrubbing is inappropriate and can cause damage to the skin. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.
question
The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. Which is the best explanation for the nurse to use when teaching the patient the reason for the binder? A. It reduces edema at the surgical site. B. It secures the dressing in place. C. It immobilizes the abdomen. D. It supports the abdomen.
answer
D. It supports the abdomen. The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to immobilize a body part (e.g., an elastic bandage applied around a sprained ankle). A binder can be used to prevent edema, for example, in an extremity but in this case is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.
question
The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management? A. Monitor vital signs every 15 minutes. B. Check pulses in the right foot. C. Keep the leg dependent. D. Apply ice.
answer
D. Apply ice. Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation (not dependent) assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.
question
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed? A. 12 B. 13 C. 20 D. 23
answer
D. 23 The best sign is a perfect score of 23. The Braden Scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden Scale in the general adult population is 18.
question
The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.) A. Place moist sterile gauze over the site. B. Gently place the organs back. C. Contact the surgical team. D. Offer a glass of water. E. Monitor for shock.
answer
A, C, E The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical emergency. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.
question
The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.) A. Hemostasis B. Maturation C. Inflammatory D. Proliferative E. Reproduction F. Reestablishment of epidermal layers
answer
A, B, C, D, The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammatory, proliferative, and maturation. Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers.
question
The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) A. "Can you easily change your position?" B. "Do you have sensitivity to heat or cold?" C. "How often do you need to use the toilet?" D. "What medications do you take?" E. "Is movement painful?" F. "Have you ever fallen?"
answer
A, B, C, E. Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, she can protect herself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with painful movement will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.
question
The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.) A. Vision B. Hyperemia C. Induration D. Blanching E. Temperature of skin
answer
B, C, D, E. Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and palpate for blanching or nonblaching. Early signs of skin damage include induration, bogginess (less-than-normal stiffness), and increased warmth at the injury site compared to nearby areas. Changes in temperature can indicate changes in blood flow to that area of the skin. Vision is not included in the skin assessment.
question
The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.) A. Cover exposed wounds. B. Mark the sites of all abrasions. C. Assess the condition of current dressings. D. Inspect the skin for abrasions and edema. E. Cleanse the area with hydrogen peroxide. F. Assess the skin at underlying areas for circulatory impairment.
answer
A, C, D, F. Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions with a dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean, and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can interfere with wound healing.
question
The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.) A. The patient's expectations are not being met. B. Skin is intact with no redness or swelling. C. Non-blanchable erythema is absent. D. No injuries to the skin and tissues are evident. E. Granulation tissue is present.
answer
B, C, D, E. Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Skin intact, nonblanchable erythema absent, no injuries, and presence of granulation tissue are all findings indicating achievement of goals and outcomes. The patient's expectations not being met indicates no progression toward goals/outcomes.
question
The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. A. Absorbs drainage through the use of exudate absorbers in the dressing B. Very soothing to the patient and do not adhere to the wound bed C. Barrier to external fluids/bacteria but allows wound to "breathe" D. Manufactured from seaweed and comes in sheet and rope form E. Oldest and most common absorbent dressing 1. Gauze 2. Transparent 3. Hydrocolloid 4. Hydrogel 5. Calcium alginate
answer
1.E 2.C 3.A 4.B 5.D
