NURSING 1023C Chapter 32 PrepU/ DOWNLOAD TO SCORE A

NURSING 1023C Chapter 32 PrepU 1. Which action should the nurse perform when applying negative pressure wound therapy? 2. A full-thickness or third-degree burn develops a leathery covering called a(an): 3. The nurse ...

NURSING 1023C Chapter 32 PrepU 1. Which action should the nurse perform when applying negative pressure wound therapy? 2. A full-thickness or third-degree burn develops a leathery covering called a(an): 3. The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? 4. The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? 5. The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? 6. The nurse would recognize which client as being particularly susceptible to impaired wound healing? 7. A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? 8. A postoperative client says during a transfer, “I feel like something just popped.” The nurse immediately assesses for: 9. The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? 10. Which is not considered a skin appendage? 11. A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? 12. A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? 13. A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother: rays. 14. The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. 15. When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? incision 16. A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery? period during which the wound undergoes changes and maturation 17. A full-thickness or third-degree burn develops a leathery covering called a(an): eschar 18. The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? “Dehiscence is when a wound has partial or total separation of the wound layers.” 19. Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? Local capillary pressure must be lower than external pressure. 20. A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? contusion 21. A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True 22. A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. 23. An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor? Adipose tissue is poorly vascularized. 24. A client’s pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? Stage II 25. A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown 26. A postoperative client is being transferred from the bed to a gurney and states, “I feel like something has just given away.” What should the nurse assess in the client? Dehiscence of the wound 27. The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? Fish 28. The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? “Reinforced adhesive skin closures will hold my wound together until it heals.” 29. The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury? stage III 30. A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Clean the wound from the top to the bottom and from the center to outside. 31. The nurse is caring for a client who has recently noted abnormal pigmentation in his skin. What is most likely deficient in the client's diet? Zinc 32. A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? use pillows to maintain a side-lying position as needed 33. When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps? Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. 34. To determine a client’s risk for pressure injury development, it is most important for the nurse to ask the client which question? “Do you experience incontinence?” 35. The nurse and client are looking at the client’s heel pressure injury. The client asks, “Why does my heel look black?” What is the nurse’s appropriate response? “That is necrotic tissue, which must be removed to promote healing.” 36. A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? Assess the client’s wound and vital signs. 37. The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Desiccation 38. A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change. Use sterile gloves. Cut the foam to the shape and measurement of the wound. Place the drape to cover the wound and an additional 3 to 5 cm. Cut a 2-cm hole in the drape. Apply a vacuum device to wound. Ensure that negative pressure has been achieved. 39. The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? Keep the swab and the inside of the culture tube sterile. 40. A client recovering from abdominal surgery sneezes and then screams, “My insides are hanging out!” What is the initial nursing intervention? applying sterile dressings with normal saline over the protruding organs and tissue 41. The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? “I will put a layer of cloth between my skin and the ice pack.” 42. After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse? Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. 43. Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? corticosteroids 44. The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? a sterile, flexible applicator moistened with saline 45. A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? secondary intention 46. A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? serosanguineous 47. A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? Subcutaneous tissue 48. A client’s hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? avulsion 49. A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Stop removing staples and inform the surgeon 50. What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? hydrocolloid dressing 51. The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? a critical care client 52. The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply. A nurse places a transparent dressing over a central venous access device insertion site. A nurse uses aseptic techniques when changing a dressing. A nurse places a drainage dressing around a drain insertion site. 53. The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication? evisceration 54. The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports “it feels numb.” What is the best action by the nurse at this time? Discontinue the therapy and assess the client. 55. The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." 56. A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to? decubitus ulcer 57. A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document? serosanguineous 58. A nurse is caring for a client at a wound care clinic. The client has a 5 × 6- cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? secondary intention 59. A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A Penrose drain promotes passive drainage into a dressing. 60. The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse’s first action? elevating and supporting the stump 61. A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention? Use clean technique instead of sterile technique if the wound is closed. 62. A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Tearing of a structure from its normal position 63. A nurse applies an aquathermia pad to the back of a client with arthritis. What administration considerations should the nurse use? Select all that apply. Apply a bath blanket over the aquathermia pad. Assess skin and pain level at baseline and ongoing. Check the water level in the aquathermia unit periodically. 64. The nurse is preparing to change a large abdominal dressing in which blood and drainage is expected. In addition to gauze, which dressing supply will the nurse gather to take in the client’s room? adhesive strips with eyelets 65. A client’s risk for the development of a pressure injury is most likely due to which lab result? albumin 2.5 mg/dL 66. The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. 67. A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: to provide drainage for bile. 68. A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot and tender upon palpation. a wound that forms exudate due to the inflammatory response 69. Which best describes the proliferative phase, the third phase of the wound healing process? reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization 70. 71. 72. 73. 74. 75. 76. 77. 78.