Question 1

The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide?

Accepted Answer

Using an alcohol-free barrier film agent after cleaning helps protect the skin from moisture and irritation, promoting healing of the rash.

Question 2

The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is oedematous and feels boggy. The edges of the wound cup in toward the centre. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

Accepted Answer

Stage IV pressure ulcers are characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. The visibility of the joint capsule of the hip indicates that the ulcer has penetrated deeply enough to expose underlying structures, which is consistent with a stage IV pressure ulcer.

Question 3

Which of the following clients would be at the highest risk of a postoperative infection?

Accepted Answer

D

Question 4

Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB colour code, which wound care should the nurse plan?

Accepted Answer

The answer of Upon assessing a pressure ulcer, the nurse...

Question 5

After completing a scheduled every-two-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?

Accepted Answer

Reactive hyperaemia is the correct term to describe a reddened area that blanches with pressure and then returns to normal color after the pressure is removed. This indicates that the blood flow has returned to the area, which is a normal physiological response to relieve pressure, not a pressure ulcer.

Question 6

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected?

Accepted Answer

The answer of The nurse is collecting a specimen from...

Question 7

The client is routinely taking steroid medications to control lung disease. In the discharge teaching plan the nurse includes information on practising good infection control because steroids cause which of the following?

Accepted Answer

Steroids suppress the inflammatory process necessary for healing, which can lead to increased risk of infection. Therefore, the nurse includes information on practising good infection control in the discharge teaching plan. The other options (A, C, D) are not directly related to the effects of steroids on infection control.

Question 8

The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale, the nurse:

Accepted Answer

The Braden Scale for Predicting Pressure Sore Risk is a standardized tool used in healthcare settings to predict a patient's risk for developing pressure ulcers. It is important for the nurse to receive specific training on how to use and interpret the results of this tool. Without training, the nurse may not be able to accurately assess a patient's risk and implement the appropriate interventions. Asking the client's permission or obtaining special assessment equipment is not necessary to use the Braden Scale, and certification is not required for its use.

Question 9

The night nurse is assuming care of a cardiac client who wears anti-embolic stockings. How should this nurse manage assessment of the skin on this client's legs?

Accepted Answer

In order to properly assess the skin on the client's legs, the anti-embolic stockings should be removed. The nurse should assess for any signs of pressure points, irritation, or swelling. It is important to assess the skin regularly to prevent skin breakdown and potential complications.

Question 10

On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first?

Accepted Answer

Covering the area with a large saline-soaked dressing is the first nursing action to take in the event of evisceration to keep the protruding organs moist and to reduce the risk of infection and further damage.

Question 11

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing?

Accepted Answer

When allowing a wound to heal by secondary intention, the wound bed should be kept moist to promote healing. Therefore, dressings that maintain moisture should be used. Choices A and B are not appropriate as they do not maintain moisture, and choice D is not necessary as air circulation is not a priority for this type of wound healing.

Question 12

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin?

Accepted Answer

Using a lifting device such as a mechanical lifter can help reduce the shearing forces on the client's skin by providing a smooth and even transfer. Coating the client's back and buttocks with baby powder or dusting the linens with corn flour would not address the issue of shearing forces. Keeping the head of the client's bed at 30 degrees may be appropriate for other reasons, but it would not specifically address shearing forces on the skin.

Question 13

A nurse is assessing a client's wound for possible infection. Wound data that would suggest a severe infection is:

Accepted Answer

Purosanguinous exudate (pus) is a sign of severe infection. Pain may also indicate the presence of infection. Swelling and redness are common signs of infection, but they can also be present in mild infection or inflammation without necessarily indicating severe infection. Serosanguinous exudate indicates the presence of blood and serum, which can be present in any wound healing process and therefore do not necessarily indicate infection. Heat without other signs of infection may indicate inflammation as well. Haemorrhagic exudate indicates excessive bleeding rather than infection.

Question 14

A client has had Braden scores of 18 and 19 and 15 and 17 Norton scores of over the last two months. Is trending of these scores significant?

Accepted Answer

Trending is somewhat significant but would be more accurate if the same scale was consistently used. Both the Braden and Norton scales assess risk for pressure ulcer development, but they use different criteria and scoring systems. Consistency in using the same scale would provide a more accurate trend analysis.

Question 15

The client has a documented stage III pressure ulcer on the right hip. What NANDA-I nursing diagnosis problem statement is most appropriate for use with this client?

Accepted Answer

Impaired Tissue Integrity is the most appropriate nursing diagnosis for a stage III pressure ulcer, as it specifically addresses damage to mucous membranes, corneal, integumentary, or subcutaneous tissues.

Question 16

The emergency department physician has closed a laceration with tissue adhesive. The nurse provides the client with instruction regarding which type of wound healing?

Accepted Answer

Tissue adhesive is typically used for wound closure in a clean, uninfected laceration that has well approximated edges, meaning that the wound edges can easily be brought together. This is known as primary intention wound healing, where the wound edges are in close approximation and heal quickly with minimal scarring. Delayed closure, secondary healing, and open approximation are all types of wound healing that do not involve the use of tissue adhesive or other methods of primary wound closure.

Question 17

An obese patient, who is five days post-abdominal surgery, rings the call bell to tell the nurse that she has 'felt something give' in her abdomen after straining to open her bowels. The nurse's priority is to:

Accepted Answer

The patient may have experienced an incisional hernia or wound dehiscence, and placing her in bed with her knees bent can reduce the pressure on her abdominal muscles and decrease the risk of further injury. Checking vital signs is important, but not the priority in this situation. Reassurance or contacting the unit manager are not appropriate actions at this time.

Question 18

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study?

Accepted Answer

The operative wound from a breast biopsy is considered a clean wound and not a clean-contaminated wound, so it would be excluded from the study. The other surgeries listed (gastric resection, lung resection, and uncomplicated abdominal hysterectomy) are considered clean-contaminated wounds and would be included in the study.

Question 19

The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection. For which category of wound should the receiving nurse plan care?

Accepted Answer

According to the CDC, a contaminated wound is one with a major break in sterile technique, such as gross spillage from the gastrointestinal tract. Therefore, since the surgical report indicates a large amount of intestinal spillage, the receiving nurse should plan care for a contaminated wound.

Question 20

The Assistant in Nursing (AIN) reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound, the nurse should:

Accepted Answer

The answer of The Assistant in Nursing (AIN) reports a...

Quiz 37: Skin Integrity and Wound Care