Question 1

The nurse is assessing a client's pressure ulcer.To determine the depth of the ulcer,the nurse should take which action?

Accepted Answer

To determine the depth of a pressure ulcer, the nurse should insert a sterile swab into the deepest part of the wound. This will help the nurse assess the extent of the tissue damage and determine the appropriate treatment plan. Measuring the width or length may help in assessing the size of the ulcer, but it will not provide information about the depth of the wound. Identifying where the ulcer is located on the clock face is a method of documenting the location of the wound, but it does not provide information about the depth of the ulcer.

Question 2

A client has episodes of bowel and bladder incontinence.When planning care for this client,the nurse would identify which nursing diagnosis as being appropriate?

Accepted Answer

Bowel and bladder incontinence can lead to skin breakdown and pressure ulcers, which can ultimately impair skin integrity. Therefore, the nursing diagnosis of Risk for Impaired Skin Integrity is the most appropriate for this client. Impaired Skin Integrity and Impaired Tissue Integrity do not directly relate to the client's incontinence, and while the client may be at risk for infection, this is not the primary concern regarding their incontinence.

Question 3

A client has a yellow wound with purulent drainage.The nurse identifies what type of wound care as appropriate for this client's wound?
Standard Text: Select all that apply.

Accepted Answer

The answer of A client has a yellow wound with...

Question 4

The nurse documents that a client's postoperative wound is purosanguinous.What did the nurse assess in this client's wound?

Accepted Answer

Purosanguinous drainage is a combination of pus and red blood cells.

Question 5

A client has several dark,thick scars on body locations from previous surgeries and injuries.The nurse realizes this occurs during which phase of wound healing?

Accepted Answer

During the maturation phase of wound healing, the scar tissue becomes thicker and darker in color. This phase can last several months to years.

Question 6

The nurse is preparing to apply a bandage to a client using the spiral reverse turn.For which body parts should the nurse use this technique when bandaging?
Standard Text: Select all that apply.

Accepted Answer

The answer of The nurse is preparing to apply a...

Question 7

During morning care,unlicensed assistive personnel observe a client's abdominal wound dressing become saturated with bright red blood.What should unlicensed assistive personnel do?

Accepted Answer

When observing a change in the wound dressing, it is important to report it to the nurse immediately so that appropriate interventions can be taken to address the source of bleeding and prevent further complications. Reinforcing the wound dressing or completing the bath first can result in delay of care and put the client at risk for further bleeding. Documenting the change is also important, but should not be the first action taken in this situation.

Question 8

A client has a wound that is going to heal through secondary intention.When instructing the client about this wound,the nurse would include which statements?
Standard Text: Select all that apply.

Accepted Answer

Secondary intention refers to the natural healing process of a wound where the wound is left open to heal on its own. This process takes longer than primary intention and results in greater scarring. There is also a greater risk of infection since the wound is not immediately closed. Minimal tissue loss is not necessarily associated with secondary intention, and closure within 5 days is not possible with this type of healing.

Question 9

The nurse is preparing to apply a moist aquathermia pack to a client's left upper leg.In which order should the nurse prepare and apply this treatment?

Accepted Answer

First, fill the reservoir with water. Then, set the desired temperature. Next, cover the pad and check for leaks. Apply the pad to the body part, and finally, secure it with tape or gauze.

Question 10

While changing a client's dressing,the nurse notes thick yellow-green drainage on the gauze.How should the nurse document this wound's drainage?

Accepted Answer

Thick yellow-green drainage is indicative of purulent drainage, which is usually a sign of infection.

Question 11

A client asks why a cold pack has been prescribed for an arm injury.What should the nurse explain to the client?
Standard Text: Select all that apply.

Accepted Answer

Cold packs cause constriction of blood vessels, which reduces swelling and inflammation, and thereby decreases pain in the affected area. Therefore, option B and C are correct. Additionally, the application of cold can also numb the nerves, thereby reducing pain, which makes option D correct. However, option A and E are incorrect as they describe the opposite effects of cold application.

Question 12

The nurse has applied an aquathermia pad to a client's back.After 15 minutes of treatment,the client says that the pack no longer is warm and asks the nurse to increase the temperature.How should the nurse evaluate this request?

Accepted Answer

Adaptation of the thermal receptors often results in the decreased sensation of warmth, so the client may not necessarily need a higher temperature. The nurse should assess the client's skin for signs of burns or redness before making any changes. A standard hot pack may not be appropriate as it does not provide the targeted moist heat therapy that an aquathermia pad does.

Question 13

The nurse identifies an older client as being at risk for impaired skin integrity.What did the nurse assess in this client?
Standard Text: Select all that apply.

Accepted Answer

Poor skin turgor, diminished pain sensation, thin epidermis, and dry skin are all factors that increase the risk of impaired skin integrity, especially in older clients. Elevated body temperature is not necessarily a factor related to impaired skin integrity.

Question 14

A client sustained several wounds on the legs caused by a fall.On the day after the injuries,the wounds appear red and edematous.The nurse identifies the stage of healing of these wounds as being in which phase?

Accepted Answer

The redness and edema are signs of inflammation, which is the first phase of wound healing.

Quiz 36: Skin Integrity and Wound Care

The nurse is assessing a client's pressure ulcer.To determine the depth of the ulcer,the nurse should take which action?

A client has episodes of bowel and bladder incontinence.When planning care for this client,the nurse would identify which nursing diagnosis as being appropriate?

A client has a yellow wound with purulent drainage.The nurse identifies what type of wound care as appropriate for this client's wound? Standard Text: Select all that apply.

The nurse documents that a client's postoperative wound is purosanguinous.What did the nurse assess in this client's wound?

A client has several dark,thick scars on body locations from previous surgeries and injuries.The nurse realizes this occurs during which phase of wound healing?

The nurse is preparing to apply a bandage to a client using the spiral reverse turn.For which body parts should the nurse use this technique when bandaging? Standard Text: Select all that apply.

During morning care,unlicensed assistive personnel observe a client's abdominal wound dressing become saturated with bright red blood.What should unlicensed assistive personnel do?

A client has a wound that is going to heal through secondary intention.When instructing the client about this wound,the nurse would include which statements? Standard Text: Select all that apply.

The nurse is preparing to apply a moist aquathermia pack to a client's left upper leg.In which order should the nurse prepare and apply this treatment?

While changing a client's dressing,the nurse notes thick yellow-green drainage on the gauze.How should the nurse document this wound's drainage?

A client asks why a cold pack has been prescribed for an arm injury.What should the nurse explain to the client? Standard Text: Select all that apply.

The nurse has applied an aquathermia pad to a client's back.After 15 minutes of treatment,the client says that the pack no longer is warm and asks the nurse to increase the temperature.How should the nurse evaluate this request?

The nurse identifies an older client as being at risk for impaired skin integrity.What did the nurse assess in this client? Standard Text: Select all that apply.

A client sustained several wounds on the legs caused by a fall.On the day after the injuries,the wounds appear red and edematous.The nurse identifies the stage of healing of these wounds as being in which phase?