Question 1

The nurse is assessing a client with a surgical wound.Which observation indicates that care has been effective for this client?

Accepted Answer

A) Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.
B) Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.
C) Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.
D) Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.

Question 2

An older adult client with poor nutritional intake is demonstrating signs of poor wound healing.Which actions by the nurse are appropriate? Select all that apply.

Accepted Answer

A) The nurse should ensure that the client receives sufficient protein and vitamins to support wound healing. The nurse should consult with a dietitian to determine ways to improve the client's intake to support wound healing. The client also needs an adequate fluid intake for wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.
B) The nurse should ensure that the client receives sufficient protein and vitamins to support wound healing. The nurse should consult with a dietitian to determine ways to improve the client's intake to support wound healing. The client also needs an adequate fluid intake for wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.
C) The nurse should ensure that the client receives sufficient protein and vitamins to support wound healing. The nurse should consult with a dietitian to determine ways to improve the client's intake to support wound healing. The client also needs an adequate fluid intake for wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.
D) The nurse should ensure that the client receives sufficient protein and vitamins to support wound healing. The nurse should consult with a dietitian to determine ways to improve the client's intake to support wound healing. The client also needs an adequate fluid intake for wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.
E) The nurse should ensure that the client receives sufficient protein and vitamins to support wound healing. The nurse should consult with a dietitian to determine ways to improve the client's intake to support wound healing. The client also needs an adequate fluid intake for wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.

Question 3

A client has a wound of the left lateral aspect of the thigh.Which action by the nurse promotes wound healing for this client?

Accepted Answer

A) To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.
B) To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.
C) To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.
D) To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.

Question 4

A client is admitted with a gunshot wound to the leg.Which nursing diagnosis would be important to include in this client's plan of care?

Accepted Answer

A) A client with a gunshot wound is at risk for infection because the wound is severe and caused by trauma. The other nursing diagnoses may or may not be appropriate for the client at this time.
B) A client with a gunshot wound is at risk for infection because the wound is severe and caused by trauma. The other nursing diagnoses may or may not be appropriate for the client at this time.
C) A client with a gunshot wound is at risk for infection because the wound is severe and caused by trauma. The other nursing diagnoses may or may not be appropriate for the client at this time.
D) A client with a gunshot wound is at risk for infection because the wound is severe and caused by trauma. The other nursing diagnoses may or may not be appropriate for the client at this time.

Question 5

A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate.The client's surgical wound has staples that are aiding in the wound healing.When documenting this client's care,which terminology best describes this client's care?

Accepted Answer

A) A wound that permits exudate to drain and then is closed with sutures, staples, or adhesive skin closures undergoes tertiary intention healing. Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.
B) A wound that permits exudate to drain and then is closed with sutures, staples, or adhesive skin closures undergoes tertiary intention healing. Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.
C) A wound that permits exudate to drain and then is closed with sutures, staples, or adhesive skin closures undergoes tertiary intention healing. Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.
D) A wound that permits exudate to drain and then is closed with sutures, staples, or adhesive skin closures undergoes tertiary intention healing. Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.

Question 6

The nurse is planning care for a client with a surgical wound.Which goal is appropriate for this client?

Accepted Answer

A) The client has impaired skin integrity because of a surgical wound. A goal of care would be for the client to have wound healing to achieve intact skin. Discharging the client to home may or may not be appropriate. The client may or may not be able to ambulate or perform independent activities of daily living.
B) The client has impaired skin integrity because of a surgical wound. A goal of care would be for the client to have wound healing to achieve intact skin. Discharging the client to home may or may not be appropriate. The client may or may not be able to ambulate or perform independent activities of daily living.
C) The client has impaired skin integrity because of a surgical wound. A goal of care would be for the client to have wound healing to achieve intact skin. Discharging the client to home may or may not be appropriate. The client may or may not be able to ambulate or perform independent activities of daily living.
D) The client has impaired skin integrity because of a surgical wound. A goal of care would be for the client to have wound healing to achieve intact skin. Discharging the client to home may or may not be appropriate. The client may or may not be able to ambulate or perform independent activities of daily living.

Question 7

A nurse working in the intensive care unit (ICU)is caring for a client who is 10 days postoperative after open abdominal surgery.The client has a well-approximated midline surgical incision that has numerous staples and a "healing ridge" noted.Which healing phase best describes the incision?

Accepted Answer

A) The proliferative phase, the second phase in healing, extends from day 3 or 4 to about day 21 post injury. If the wound is sutured, a raised "healing ridge" appears under the intact suture line. The synthesis phase does not exist. The other choices are incorrect.
B) The proliferative phase, the second phase in healing, extends from day 3 or 4 to about day 21 post injury. If the wound is sutured, a raised "healing ridge" appears under the intact suture line. The synthesis phase does not exist. The other choices are incorrect.
C) The proliferative phase, the second phase in healing, extends from day 3 or 4 to about day 21 post injury. If the wound is sutured, a raised "healing ridge" appears under the intact suture line. The synthesis phase does not exist. The other choices are incorrect.
D) The proliferative phase, the second phase in healing, extends from day 3 or 4 to about day 21 post injury. If the wound is sutured, a raised "healing ridge" appears under the intact suture line. The synthesis phase does not exist. The other choices are incorrect.

Question 8

A client recovering from abdominal surgery tells the nurse that "something popped" in the abdominal incision.Upon inspection,the nurse finds that evisceration has occurred.What actions by the nurse are appropriate? Select all that apply.

Accepted Answer

A) Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound. The client should not be turned onto the abdomen.
B) Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound. The client should not be turned onto the abdomen.
C) Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound. The client should not be turned onto the abdomen.
D) Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound. The client should not be turned onto the abdomen.
E) Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound. The client should not be turned onto the abdomen.

Question 9

An older adult client diagnosed with chronic obstructive pulmonary disease (COPD)is scheduled for a total knee replacement.What should the nurse include in this client's plan of care?

Accepted Answer

A) Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. The nurse should assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need an adequate intake of protein for wound healing; protein should not be restricted.
B) Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. The nurse should assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need an adequate intake of protein for wound healing; protein should not be restricted.
C) Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. The nurse should assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need an adequate intake of protein for wound healing; protein should not be restricted.
D) Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. The nurse should assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need an adequate intake of protein for wound healing; protein should not be restricted.

Quiz 21: Tissue Integrity