Deck 18: Clients with Wounds

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Question
A client has a small, shallow wound with a red base that does not require debridement. The dressing the nurse would choose when covering this wound is a

A) dry woven gauze fastened with adhesive tape.
B) non-adhering dressing with antibiotic ointment.
C) wet nonwoven gauze.
D) wet-to-dry gauze dressing.
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Question
A nurse is caring for four clients. Which client should the nurse assess first? The client with a/an

A) eviscerated abdominal wound from surgery yesterday.
B) infected lower leg ulcer and diabetes, who needs a blood sugar measurement.
C) large open infected wound and temperature of 99.9° F.
D) operative incision covered with a clean, dry dressing from surgery 8 hours ago.
Question
The edges of a client's appendectomy incision are approximated, and no drainage is noted. The nurse documents on the client's wound record that the incision appears to be healing by

A) granulation.
B) primary intention.
C) secondary intention.
D) tertiary intention.
Question
The nurse caring for a client receiving wet-to-dry dressings for mechanical debridement of a large wound would be aware that proper technique requires that the dressing should

A) be left in place about 12 hours.
B) be removed when it is totally dry.
C) cause slight bleeding when removed to be effective.
D) only be moist, not wet, when applied.
Question
A client must do dressing changes at home on a clean, but open, surgical wound. The nurse determines that goals for discharge instructions have been met when the client says:

A) "I will be sure to keep the skin surrounding the wound dry."
B) "I will sit under a heat lamp for 30 minutes a day to help dry up the drainage."
C) "If I run out of saline, I can irrigate the wound with half strength peroxide."
D) "Pulling out the dried up dressings will help clean the wound out."
Question
The nurse who is using an enzymatic debridement ointment will

A) apply the ointment liberally over large areas.
B) keep the area moist after application.
C) medicate the client before applying ointment to viable tissue.
D) use the ointment cautiously on neoplastic ulcers.
Question
A nurse is changing a dressing over a client's abdominal surgical incision. Which action by the nurse is most important?

A) Apply dressings using aseptic or sterile technique.
B) Irrigate the wound with copious amounts of solution.
C) Use strict sterile technique, including sterile gloves.
D) Wash the suture line carefully to remove debris.
Question
A client is being discharged with a large wound on the right ankle that has cellulitis. The client is obese, smokes 2 packs of cigarettes a day, and is sedentary. In the discharge instructions, which lifestyle modification would be most important for the nurse to include? The client should

A) drink more water.
B) lose weight.
C) start an exercise routine.
D) stop smoking.
Question
A client with an open wound develops a temperature of 99.8° F. The most appropriate action by the nurse is to

A) administer an antipyretic.
B) continue to monitor the client's temperature.
C) cool the client's environment.
D) keep the client warm.
Question
When caring for a client with a wound healing by secondary intention, the nurse considers during care planning that this type of wound is

A) healed with skin grafts.
B) prone to dehiscence.
C) sealed with sutures.
D) susceptible to infection.
Question
On removing a dressing from a client on the third postoperative day, the nurse notes thin, pink-colored drainage and documents this as

A) serous.
B) sanguineous.
C) serosanguineous.
D) purulent.
Question
A client has a large, sacral pressure ulcer with a red wound base and no drainage. Which solution would the nurse select as the most appropriate solution for cleansing this wound?

A) A weak iodine solution
B) Dakin's solution
C) Half-strength hydrogen peroxide
D) Normal saline
Question
To assist in the healing of a large leg ulcer, the nurse applies wet dressings to the wound to promote

A) angiogenesis.
B) chemotaxis.
C) epithelialization.
D) wound contraction.
Question
A client's dressing orders include calcium alginate (Kalistat). The nurse instructs the client that this application is appropriate for a(n)

A) black wound.
B) draining wound.
C) infected wound.
D) red wound.
Question
A nurse is caring for a client with a chronic lower leg wound caused by venous insufficiency. Which action by the nurse is most appropriate?

A) Apply ice to the surrounding tissue.
B) Elevate the leg and apply compression stockings.
C) Keep the leg in one position to avoid further injury.
D) Position the leg flat with heels elevated off the bed.
Question
On a client's admission to the hospital, the nurse notes that the client has a yellow sacral decubitus ulcer. The nurse anticipates that the most appropriate wound treatment would be

A) applying antibiotic ointment.
B) surgical removal of eschar.
C) using wet-to-dry dressings.
D) vigorous cleansing with a Water Pik.
Question
The nurse is aware that the process by which capillary permeability is altered to allow the large neutrophils to pass through the capillary wall and to the wound site is called

A) banding.
B) marginating.
C) replicating.
D) segmenting.
Question
The nurse predicts that the wound capable of becoming "ideally healed" is a(n)

A) abdominal incision.
B) burn scar on the leg.
C) cancerous lesion on the inside of the cheek.
D) severe acne on the face.
Question
A client has a chronic, nonhealing ulcer on the lower leg. The nurse thinks the client could benefit from negative-pressure wound therapy. The most appropriate action by the nurse would be to

A) ask the charge nurse to discuss the matter with the physician.
B) call the physician and request an order for a negative pressure machine.
C) keep track of supplies used currently to estimate the cost of continuing the present regimen.
D) request the physician write an order to consult the wound care nurse.
Question
A frail client with multiple chronic medical conditions has a chronic, infected, malodorous wound. The client begins to cry when the nurse tries to explain to the client an aggressive approach to wound care. The nurse should revise the plan to focus on

A) better pain control so the client can tolerate the aggressive therapy.
B) palliative care and quality of life.
C) the client's emotional barrier to the recommended treatment.
D) the possibility of eventual amputation.
Question
A client comes to the clinic with a wound that does not seem to be healing. Which assessments should the nurse make on this client specific to the wound? (Select all that apply.)

A) Client's height and weight
B) Diet and nutritional history
C) Long-term use of steroids
D) Size of the wound and amount of drainage
E) Smoking and alcohol intake
Question
The nurse informs the client that to reduce scarring, facial sutures are removed in

A) 1 to 2 days.
B) 4 to 7 days.
C) 8 to 10 days.
D) 12 to 14 days.
Question
Four days after a client's surgery, the nurse assesses a collagen mass under the client's suture line as an indication of

A) abscess.
B) edema.
C) healing ridge.
D) infection.
Question
A client is being discharged and will need to perform wound care and dressing changes in the home on a large, open wound. When designing a teaching plan for discharge, the nurse should include which of the following elements? (Select all that apply.)

A) A videotape of the wound care procedure if possible
B) Appropriate ways to irrigate the wound
C) Cost of wound care supplies
D) Detailed written instructions
E) Types of supplies the client will need
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Deck 18: Clients with Wounds
1
A client has a small, shallow wound with a red base that does not require debridement. The dressing the nurse would choose when covering this wound is a

A) dry woven gauze fastened with adhesive tape.
B) non-adhering dressing with antibiotic ointment.
C) wet nonwoven gauze.
D) wet-to-dry gauze dressing.
wet nonwoven gauze.
2
A nurse is caring for four clients. Which client should the nurse assess first? The client with a/an

A) eviscerated abdominal wound from surgery yesterday.
B) infected lower leg ulcer and diabetes, who needs a blood sugar measurement.
C) large open infected wound and temperature of 99.9° F.
D) operative incision covered with a clean, dry dressing from surgery 8 hours ago.
eviscerated abdominal wound from surgery yesterday.
3
The edges of a client's appendectomy incision are approximated, and no drainage is noted. The nurse documents on the client's wound record that the incision appears to be healing by

A) granulation.
B) primary intention.
C) secondary intention.
D) tertiary intention.
primary intention.
4
The nurse caring for a client receiving wet-to-dry dressings for mechanical debridement of a large wound would be aware that proper technique requires that the dressing should

A) be left in place about 12 hours.
B) be removed when it is totally dry.
C) cause slight bleeding when removed to be effective.
D) only be moist, not wet, when applied.
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5
A client must do dressing changes at home on a clean, but open, surgical wound. The nurse determines that goals for discharge instructions have been met when the client says:

A) "I will be sure to keep the skin surrounding the wound dry."
B) "I will sit under a heat lamp for 30 minutes a day to help dry up the drainage."
C) "If I run out of saline, I can irrigate the wound with half strength peroxide."
D) "Pulling out the dried up dressings will help clean the wound out."
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k this deck
6
The nurse who is using an enzymatic debridement ointment will

A) apply the ointment liberally over large areas.
B) keep the area moist after application.
C) medicate the client before applying ointment to viable tissue.
D) use the ointment cautiously on neoplastic ulcers.
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Unlock Deck
k this deck
7
A nurse is changing a dressing over a client's abdominal surgical incision. Which action by the nurse is most important?

A) Apply dressings using aseptic or sterile technique.
B) Irrigate the wound with copious amounts of solution.
C) Use strict sterile technique, including sterile gloves.
D) Wash the suture line carefully to remove debris.
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
8
A client is being discharged with a large wound on the right ankle that has cellulitis. The client is obese, smokes 2 packs of cigarettes a day, and is sedentary. In the discharge instructions, which lifestyle modification would be most important for the nurse to include? The client should

A) drink more water.
B) lose weight.
C) start an exercise routine.
D) stop smoking.
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Unlock Deck
k this deck
9
A client with an open wound develops a temperature of 99.8° F. The most appropriate action by the nurse is to

A) administer an antipyretic.
B) continue to monitor the client's temperature.
C) cool the client's environment.
D) keep the client warm.
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
10
When caring for a client with a wound healing by secondary intention, the nurse considers during care planning that this type of wound is

A) healed with skin grafts.
B) prone to dehiscence.
C) sealed with sutures.
D) susceptible to infection.
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
11
On removing a dressing from a client on the third postoperative day, the nurse notes thin, pink-colored drainage and documents this as

A) serous.
B) sanguineous.
C) serosanguineous.
D) purulent.
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k this deck
12
A client has a large, sacral pressure ulcer with a red wound base and no drainage. Which solution would the nurse select as the most appropriate solution for cleansing this wound?

A) A weak iodine solution
B) Dakin's solution
C) Half-strength hydrogen peroxide
D) Normal saline
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
13
To assist in the healing of a large leg ulcer, the nurse applies wet dressings to the wound to promote

A) angiogenesis.
B) chemotaxis.
C) epithelialization.
D) wound contraction.
Unlock Deck
Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
14
A client's dressing orders include calcium alginate (Kalistat). The nurse instructs the client that this application is appropriate for a(n)

A) black wound.
B) draining wound.
C) infected wound.
D) red wound.
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
15
A nurse is caring for a client with a chronic lower leg wound caused by venous insufficiency. Which action by the nurse is most appropriate?

A) Apply ice to the surrounding tissue.
B) Elevate the leg and apply compression stockings.
C) Keep the leg in one position to avoid further injury.
D) Position the leg flat with heels elevated off the bed.
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
16
On a client's admission to the hospital, the nurse notes that the client has a yellow sacral decubitus ulcer. The nurse anticipates that the most appropriate wound treatment would be

A) applying antibiotic ointment.
B) surgical removal of eschar.
C) using wet-to-dry dressings.
D) vigorous cleansing with a Water Pik.
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
17
The nurse is aware that the process by which capillary permeability is altered to allow the large neutrophils to pass through the capillary wall and to the wound site is called

A) banding.
B) marginating.
C) replicating.
D) segmenting.
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Unlock Deck
k this deck
18
The nurse predicts that the wound capable of becoming "ideally healed" is a(n)

A) abdominal incision.
B) burn scar on the leg.
C) cancerous lesion on the inside of the cheek.
D) severe acne on the face.
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
19
A client has a chronic, nonhealing ulcer on the lower leg. The nurse thinks the client could benefit from negative-pressure wound therapy. The most appropriate action by the nurse would be to

A) ask the charge nurse to discuss the matter with the physician.
B) call the physician and request an order for a negative pressure machine.
C) keep track of supplies used currently to estimate the cost of continuing the present regimen.
D) request the physician write an order to consult the wound care nurse.
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Unlock Deck
k this deck
20
A frail client with multiple chronic medical conditions has a chronic, infected, malodorous wound. The client begins to cry when the nurse tries to explain to the client an aggressive approach to wound care. The nurse should revise the plan to focus on

A) better pain control so the client can tolerate the aggressive therapy.
B) palliative care and quality of life.
C) the client's emotional barrier to the recommended treatment.
D) the possibility of eventual amputation.
Unlock Deck
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Unlock Deck
k this deck
21
A client comes to the clinic with a wound that does not seem to be healing. Which assessments should the nurse make on this client specific to the wound? (Select all that apply.)

A) Client's height and weight
B) Diet and nutritional history
C) Long-term use of steroids
D) Size of the wound and amount of drainage
E) Smoking and alcohol intake
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Unlock for access to all 24 flashcards in this deck.
Unlock Deck
k this deck
22
The nurse informs the client that to reduce scarring, facial sutures are removed in

A) 1 to 2 days.
B) 4 to 7 days.
C) 8 to 10 days.
D) 12 to 14 days.
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Unlock Deck
k this deck
23
Four days after a client's surgery, the nurse assesses a collagen mass under the client's suture line as an indication of

A) abscess.
B) edema.
C) healing ridge.
D) infection.
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Unlock Deck
k this deck
24
A client is being discharged and will need to perform wound care and dressing changes in the home on a large, open wound. When designing a teaching plan for discharge, the nurse should include which of the following elements? (Select all that apply.)

A) A videotape of the wound care procedure if possible
B) Appropriate ways to irrigate the wound
C) Cost of wound care supplies
D) Detailed written instructions
E) Types of supplies the client will need
Unlock Deck
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Unlock Deck
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