Proper Use of Triangle Arm Sling
Unlock all answers in this set
Unlock answersquestion
What is an indication of proper use of a triangle arm sling? 1. The elbow is kept flexed at 90 degrees or more. 2. The knot is placed on either side of the vertebrae of the neck. 3. The sling extends to just proximal of the hand. 4. The sling is removed q2h to assess for circulation and skin integrity.
answer
2. The knot is placed on either side of the vertebrae of the neck; The knot of the triangle sling must be kept off the spinal processes because this would be uncomfortable and put unnecessary pressure on the vertebrae. The elbow should be flexed slightly less than 80 degrees (not > 90 as in option 1) so the hand is above the elbow to prevent dependent swelling. The sling must extend past the wrist in order to support the hand. Although the sling must be removed to check for circulation and skin integrity, every 2 hours (option 4) is unnecessarily frequent and impractical.
question
Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is at increased risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.
answer
2. Implement a turning schedule; the client is at increased risk for skin breakdown; A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.
question
Proper technique for performing a wound culture includes what? 1. Cleansing the wound prior to obtaining the specimen. 2. Swabbing for the specimen in the area with the largest collection of drainage. 3. Removing crusts or scabs with sterile forceps and then culturing the site beneath. 4. Waiting 8 hours following a dose of antibiotic to obtain the specimen.
answer
1. Cleansing the wound prior to obtaining the specimen; Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride a wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a does will not significantly affect the concentration of wound organisms.
question
Which of the following items are used to perform wound care irrigation? Select all that apply. 1. Clean gloves 2. Sterile gloves 3. Refrigerated irrigating solution 4. 60-mL syringe
answer
1, 2, and 4; To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be at room or body temperature-- certainly not refrigerated.
question
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1. Alginate 2. Dry Gauze 3. Hydrocolloid 4. No dressing indicated.
answer
3. Hydrocolloid; Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.
question
Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed
answer
1, 3, & 4; Risk factors for pressure ulcers include a low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chance of skin breakdown.
question
Thirty minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that: 1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation) 2. It will be acceptable to leave the pad in place for another thirty minutes
answer
1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation); The heating pads need to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect resulting in vasoconstriction. Lowering the temperature, but still delivering heat -dry or moist- will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.
question
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is: 1. Risk for Impaired Skin Integrity 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection
answer
2. Impaired Skin Integrity; The client has an actual impairment of the skin due to the rash and the scratching so is no longer "at risk". Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected.
question
Which statement, if made by the client or family member, would indicate the need for further teaching? 1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse. 2. Putting foam pads under the heels or other bony areas can help decrease pressure. 3. If a person cannot turn himself in bed, someone should help them change position q4h. 4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.
answer
3. If a person cannot turn himself in bed, someone should help them change position q4h; Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires additional teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.
question
The client is only comfortable lying on the right side or left side (not on the back or stomach). List at least four potential sites of pressure ulcers the nurse must assess.
answer
These are important areas to assess. Potential ulcer sites for side-lying clients include: 1. Ankles 2. Knees 3. Trochanters 4. Ilia 5. Shoulders 6. Ears
question
Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? 1. Walking without shoes 2. Sitting in Fowler's position 3. Lying supine in bed 4. Using a heating pad
answer
2. Sitting in Fowler's position; None of the other movements or situations creates the combination of friction and pressure with downward movement seen in bedridden clients positioned in Fowler's position.
question
The client at greatest risk for postoperative wound infection is: 1. A 3-month-old infant postoperative from pyloric stenosis repair 2. A 78-year-old postoperative from inguinal hernia repair 3. An 18-year-old drug user postoperative from removal of a bullet in the leg 4. A 32-year-old diabetic postoperative from an appendectomy
answer
3. An 18-year-old drug user postoperative from removal of a bullet in the leg; All are at risk for infection. Answer 3 is at greatest risk, because the bullet is unclean, and a drug user is at great risk for immune deficiency.
question
Why is a client with fever often predisposed to pressure ulcers? 1. Pain perception is diminished. 2. Medications given to relieve fever cause edema. 3. The client may be too weak to change position. 4. Increased metabolism causes increased oxygen needs that cannot be met.
answer
4. Increased metabolism causes increased oxygen needs that cannot be met; Increased metabolism causes increased oxygen needs that cannot be met; therefore, a client with a fever is predisposed to pressure ulcers. Answers 1 and 2 are false statements. Answer 3 may be a cause of pressure ulcers and may occur in clients with fever, but it is not directly related.
question
Black wounds are treated with debridement. Which type of debridement is most selective and least damaging? 1. Debridement with scissors 2. Debridement with wet to dry dressings 3. Mechanical debridement 4. Chemical debridement
answer
4. Chemical debridement; Chemical debridement is either done with enzyme agents or autolytic agents. Answer 1 is a type of sharp debridement. Answers 2 and 3 are mechanical and less precise than chemical.
question
A client's wound is draining thick yellow material. The nurse correctly describes the drainage as: 1. Sanguineous 2. Serous-sanguineous 3. Serous 4. Purulent
answer
4. Purulent; Drainage is described as purulent. Sanguineous and Serous-sanguineous contain blood. Serous is clear and watery.
question
The nurse cares for a client with a wound in the late regeneration phase of tissue repair. The wound may be protected by applying a: 1. Transparent film 2. Hydrogel dressing 3. Collogenase dressing 4. Wet to dry dressing
answer
1. Transparent film; Wounds in the regeneration phase of healing need to be protected as new tissue grows. Answers 2, 3, and 4 are dressings used to remove nonviable tissue.
question
A client has a diabetic stasis ulcer on the lower leg. The nurse uses a hydrocolloid dressing to cover it. The procedure for application includes: 1. Cleaning the skin and wound with betadine 2. Removing all traces of residues for the old dressing 3. Choosing a dressing no more than quarter-inch larger than the wound size 4. Holding in place for one minute to allow it to adhere
answer
4. Holding in place for one minute to allow it to adhere; The skin is cleansed with normal saline or a mild cleanser. Residue of old dressings will dissolve. The dressing size is to be 3-4 cm (1.5 inches) larger than the size of the wound.
question
A home health nurse visits a client who twisted an ankle in the morning. The client has an ice bag on the ankle. Which one of the client's chronic conditions contraindicates the use of ice? 1. Gastritis 2. Diabetes 3. Glaucoma 4. Osteoporosis
answer
2. Diabetes; Diabetes contradicts the use for ice. Clients with neurological or circulatory impairment are at risk for injury with ice use.
question
A client is admitted to the Emergency Department after a motorcycle accident that resulted in the client's skidding across a cement parking lot. Since the client was wearing shorts, there are large areas on the legs where the skin is ripped off. This wound is best described as: 1. Abrasion 2. Unapproximated 3. Laceration 4. Eschar
answer
3. Laceration; Laceration best describes the wound, because skin is ripped off. An abrasion is a scrape. Unapproximated is a general term for a wound that is not closed. Eschar is a scab-like covering over a wound.
question
What physiological conditions are contraindicated for using heat as a therapy? (Select all that apply.) 1. The first 24 hours of injury 2. Active hemorrhage 3. Noninflammatory edema 4. Localized malignant tumor
answer
All of the above; Heat causes vasodilatation and increases blood flow to the affected area bringing oxygen, nutrients, antibodies, and leukocytes. A possible disadvantage of heat is that it increases capillary permeability, which allows extracellular fluid and substances to pass through the capillary walls and may result in edema or an increase in preexisting edema. Contraindications include: the first 24 hours of injury, active hemorrhage, noninflammatory edema, localized malignant tumor, and skin disorder that causes redness or blisters.
question
A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention? 1. Cut in the skin from a kitchen knife 2. Excoriated perineal area 3. Abrasion of the skin 4. Pressure ulcer
answer
1. Cut in the skin from a kitchen knife; A cut in the skin by a sharp instrument with minimal tissue loss can heal by primary intention when the wound edges are lightly pulled together (approximated). Excoriations, abrasions, and pressure ulcers heal by secondary, not primary. Secondary intention healing occurs when wound edges are not approximated because of full-thickness tissue loss; the wound is left open until it fills with new tissue. Abrasions and excoriations are injuries to the surface of the skin.
question
Which condition places the client at the greatest risk for developing an infection? 1. Implantation of a prosthetic device 2. Burns over more than 20% of the body 3. Presence of an indwelling urinary catheter 4. More than 2 puncture sites from laparoscopic surgery
answer
2. Burns over more than 20% of the body, Burns more than 20% of the client's total body surface are generally considered major burn injuries. When the skin is damaged by a burn the underlying tissue is left unprotected and the individual is at risk for infection. The greater the extent and deeper the depth of the burn, the higher the risk is for infection. Prosthetic devices are surgically implanted under sterile conditions to minimize risk of infection. Indwelling urinary catheters are implanted under sterile conditions and are considered closed systems where sterile technique is maintained. Laparoscopic surgery is also performed using sterile technique.
question
A nurse is concerned about a client's ability to withstand exposure to pathogens. What blood component should the nurse monitor?
answer
Neutrophils; Neutrophils are the most numerous leukocytes (white blood cells) and are a primary defense against infection because they ingest and destroy microorganisms (phagocytosis).
question
A practitioner orders a wound to be packed with a wet-to-damp gauze dressing. What should the nurse explain to the client is the primary reason for this type of dressing?
answer
Packing the wound with wet-to-damp dressings allows epidermal cells to migrate more rapidly across the bed of the wound surface than dry dressings, thereby facilitating healing. Wet-to-damp dressings will also wick exudate up and away from the base of the wound and help to increase resistance to a wound infection.
question
A client has a wound infection. What local human response should the nurse expect to identify?
answer
Edema; Chemical mediators increase the permeability of small blood vessels, thereby causing fluid to move into the interstitial compartment, resulting in local edema.
question
A client has wound that is healing by secondary intention. To best support the healing of the wound, the nurse should expect the practitioner's order to state, "Clean wound with:"
answer
"Clean wound with normal saline and apply a wet-to-damp dressing"; Cleaning with normal saline will not damage fibroblasts. Wet-to-damp dressings allow epidermal cells to migrate more rapidly across the wound surface than dry dressings, thereby facilitating wound healing.
question
Which client information collected by the nurse reflects a systemic response to a wound infection? 1. Hyperthermia 2. Exudate 3. Edema 4. Pain
answer
1. Hyperthermia; Hyperthermia is a common systemic response to infection. With hyperthermia, microorganisms or endotoxins stimulate phagocytotic cells that release pyrogens, which stimulate the hypothalamic thermoregulatory center, resulting in fever. Exudate, edema, and pain are all signs of infection but are considered local responses to infection or injury.
question
You find that your newly assigned client has very shiny skin on their legs, has little or no leg hair, and the client reports that their skin damages easily. You would suspect that these signs and symptoms are related to: 1. Overuse of caustic products to strip the leg hair. 2. Chronic neurological pathology. 3. Impaired peripheral arterial circulation. 4. Inherited reduction in sweat glands and hair follicles.
answer
3. Impaired peripheral arterial circulation; Shiny skin on the legs, reduction in or absence of leg hair, and skin that damages easily is often related to impaired peripheral arterial circulation.
question
Your client has a pressure ulcer over the sacral area that is believed to be due to shearing force. The client's family asks you to explain shearing force. You would be most accurate if you tell the family that shearing force involves: 1. A tearing of the muscle tissue due to a considerable downward force. 2. A sudden break in skin integrity due to being pulled against the bed linens. 3. A superficial skin fold getting pinched, and tissues irritated by the pressure. 4. Superficial skin surface relatively unmoving in relation to the bed surface.
answer
3. A superficial skin fold getting pinched, and tissues irritated by the pressure; Shearing force is a combination of friction and pressure with skin surface unmoving in relation to the bed surface, while deeper tissue attached to the skeleton tends to move with the body.
question
When working with an older person, you would keep in mind that the older person is most likely to experience which of following changes with aging? 1. Thinning of the epidermis 2. Thickening of the epidermis 3. Oiliness of the skin 4. Increased elasticity of the skin
answer
1. Thinning of the epidermis, The epidermis thins with aging, and there is decreased strength and elasticity of the skin, increased dryness and scaliness of the skin, and diminished pain perception due to decreased sensation of pressure and light touch.
question
You are caring for an assigned client and notice a superficial ulcer on the client's buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV
answer
2. Stage II; Stage I pressure ulcer involves a nonblanchable erythema of intact skin, while a stage II involves a partial-thickness skin loss involving epidermis, dermis, or both, with the ulcer being superficial and presenting as an abrasion, blister, or shallow crater.
question
When receiving a report at the beginning of your shift, you learn that your assigned client has a surgical incision that is healing by primary intention. You know that your client's incision is: 1. Well approximated, with minimal or no drainage. 2. Going to take a little longer than usual to heal. 3. Going to have more scarring than most incisions. 4. Draining some serosanguineous drainage.
answer
1. Well approximated, with minimal or no drainage; Primary intention means that the wound edges are well approximated, with minimal or no tissue loss as well as formation of minimal granulation tissue and scarring.
question
A client's family asks you to explain some keloid scars that the client developed. The best explanation of the keloid scars would be that keloid scars are: 1. Due to a relatively rare inherited tendency. 2. Caused by an abnormal amount of collagen being laid down in scar formation. 3. Most common in pale-skinned people of Northern European ancestry. 4. Caused by repeated and abrupt early disruption of eschar being formed.
answer
2. Caused by an abnormal amount of collagen being laid down in scar formation; Keloid scars are due to an abnormal amount of collagen being laid down in scar formation in the maturation phase, and they are more apt to occur in a dark-skinned person.
question
When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional vomiting and is not keeping fluids down well, which of the following would you be most concerned about? 1. Post surgical hemorrhage and anemia 2. Wound dehiscence and evisceration 3. Impaired skin integrity and decubitus ulcers 4. Loss of motility and paralytic illeus
answer
2. Wound dehiscence and evisceration; Wound dehiscence is most likely to occur 4 to 5 days postoperatively, and risk factors include obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration.
question
You are at the scene of an accident and find the victim has a bleeding lower leg wound. After flushing the wound with water and covering it with a clean dressing, you find the dressing has been saturated with blood. Which of the following would be the best action to take in this case? 1. Lower the extremity while applying pressure to the wound. 2. Take off the first dressing and apply another clean or sterile dressing. 3. Encircle the client's ankle with your hands and apply pressure. 4. Reinforce the first layer of dressing with a second layer of dressing.
answer
4. Reinforce the first layer of dressing with a second layer of dressing; To control severe bleeding, apply direct pressure to the wound and elevate the extremity. If the dressing becomes saturated, apply a second layer. Removing the first dressing may disturb blood clots and increase the bleeding.
