Question 1

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?
(Select all that apply)

Accepted Answer

The spiral reverse turn technique is commonly used to bandage the forearm and lower leg. It is not commonly used for finger, upper leg and upper arm bandages.

Question 2

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?
(Select all that apply)

Accepted Answer

A wound that is healing through secondary intention means that the wound is left open to heal on its own, without sutures or other closure methods. This process can take longer than wounds healing through primary intention, where the edges are brought together to heal. Therefore, statement B is incorrect. Since the wound is open, there is potential for more tissue loss, leading to larger scars, making statements A and D accurate. When a wound is open, it is more susceptible to infection, which is why statement E is also correct.

Question 3

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

The maturation phase of wound healing is characterized by the remodeling of collagen fibers and the strengthening of wound tissue, which can result in the formation of scars. Dark, thick scars are often a result of excessive collagen production during this phase.

Question 4

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, which will provide information about the tissue layers affected. Measuring the width or length of the ulcer will not provide information about its depth. Using the face of a clock to identify the location of the ulcer is a helpful method of documentation, but it does not provide information about the depth of the wound.

Question 5

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

Purulent drainage is thick and yellow-green in color, indicating the presence of pus. This type of drainage is typically found in infected wounds and should be documented as such. Serous drainage is clear and watery, sanguineous drainage is bright red and indicates fresh bleeding, and serosanguinous drainage is pink and indicates a mixture of clear and bloody drainage. None of these options accurately depict the type of drainage observed in this particular wound.

Question 6

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

Accepted Answer

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

Question 7

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 mixture of pus and blood. This indicates that the wound is healing and the body is responding to the surgical trauma.

Question 8

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 appearance of redness and edema indicates that the wounds are in the inflammatory phase of healing. This phase occurs immediately after the injury and is characterized by the body's response to the injury, such as inflammation and the formation of a clot to stop bleeding. The proliferative phase comes next, during which new tissue is formed, followed by the maturation phase, where the tissue becomes more organized and stronger. The remodeling phase is the final phase of healing and involves the reshaping of tissue to its original form and function.

Question 9

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

If a client's wound dressing becomes saturated with bright red blood, it is important to report the changes to the nurse immediately. The nurse will need to assess the wound and determine if any interventions are necessary. Reinforcing the wound with supplies on the client's bedside table or documenting the condition of the dressing are not appropriate actions without first notifying the nurse. Completing the bath before reporting the change may delay necessary interventions and put the client at risk.

Question 10

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

The client's episodes of bowel and bladder incontinence put them at risk for developing impaired skin integrity, such as pressure ulcers. Therefore, the appropriate nursing diagnosis would be "Risk for Impaired Skin Integrity." Impaired Tissue Integrity and Impaired Infection do not directly apply to the client's condition.

Question 11

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

Accepted Answer

The application of cold constricts blood vessels, which helps to reduce swelling and inflammation, and reduces localized pain. Cold therapy decreases inflammation by reducing blood flow to the affected area, which also helps to decrease pain. While cold therapy may provide a calming effect, it is not typically used for its sedative properties.

Question 12

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

Accepted Answer

The nurse assessed poor skin turgor which indicates dehydration, diminished pain sensation which could lead to inadequate movement, thin epidermis which is a common finding in older adults, and dry skin which increases the risk for skin breakdown. Elevated body temperature is not directly related to impaired skin integrity.

Question 13

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

The decreased sensation of warmth may be due to adaptation of the thermal receptors, and increasing the temperature may not be necessary. The nurse may assess the client's skin for any signs of damage and assess the client's perception of heat to ensure that there is no injury or adverse reaction to the therapy. Switching to another form of heat therapy may also be considered if the aquathermia pad is not effective.

Question 14

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?
A)Use tape or gauze ties to hold the pad in place.
B)Set the desired temperature according to the manufacturer's instructions.
C)Apply the pad to the body part.The treatment is usually continued for 30 minutes.
D)Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer.
E)Cover the pad and plug in the unit.Check for any leaks or malfunctions of the pad before use.

Accepted Answer

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

Quiz 36: Skin Integrity and Wound Care

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? (Select all that apply)

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? (Select all that apply)