Chapter 31: Skin Integrity and Wound Care

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan?

A nurse caring for patients in PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage?

A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? 1: [blank_start]Notify the physician of the situation[blank_end] 2: [blank_start]Cover exposed tissue w/sterile towels[blank_end] 3. [blank_start]Place patient in low Fowler's position[blank_end]

A patient age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now". Based on this statement, what nursing diagnosis would be most appropriate?

A patient is admitted with nonhealing surgical wound. Which nursing action is most effective inpreventing a wound infection?

A nurse who is changing dressing of postoperative patient in the hospital documents various phases of wound healing on the patient charts. Which statement accurately describe these stages?

The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound?

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure?

A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (his replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient?

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured are. What response indicates that the patient understand the explanation?

A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient?

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as:

The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red". What would be the priority nursing intervention for this type of wound?

A nurse is developing a plan of care related to prevention of pressure ulcers for residents in a long-term facility. Which action would be a priority in preventing a patient from developing a pressure ulcer?

A nurse is measuring the depth of patient's puncture wound. Which technique is recommended?

A nurse is cleaning the wound of a gun shot victim. Which of the following is a recommended guideline for this procedure?

The nurse would recognize which of the following clients as being particularly susceptible to impaired wound healing?

A nurse prepares to give a sitz bath to a client after perianal surgery. Which of the following would be most important for the nurse to do?

Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing?

A home care nurse is visiting a client as part of a regular visit. The client's daughter falls and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress based on the understanding that cold achieves which effect?

Which of the following actions should the nurse perform when applying negative pressure wound therapy?

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

What observation should the nurse note about a client's open wound if the wound is healing by the third intention?

What type of dressing has the advantage of remaining in place for 3-7 days, resulting in less interference with wound healing?

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate?