Download NUR 101 Final Exam Study Guide: Skin Integrity and Wound Care and more Exams Advanced Education in PDF only on Docsity!
NUR 101 Final Exam Study Guide
Factors that affect skin integrity - correct answer ✔✔1. age (turgor, drier, reduced collagen, more prone to injury)-frail skin
- Bedrest/immobility-decrease pressure and shear
- nutrition/hydration (protein, C, zinc, copper)
- sensation level (diminished)
- impaired circulation-(impaired arterial circulation causes muscle atrophy and thin tissue; impaired venous circulation causes buildup of waste in blood, causes edema, ulceration, skin breakdown)-loose clothing
- moisture-incontinence, fever cause moisture and skin maceration (fever increases metabolic rate ans this tissue demand for oxygen)
- Edema-decreases skin elasticity; compression stockings
- Glycemic control-diabetes increases infection risk and delayed wound healing
- Drugs-causes itching, rashes, photosensitivity, pigmentation changes; vasoconstrictors, steroids (inhibit wound healing); anticoagulants can result in pooling of blood in subcutaneous tissue, can cause hematoma; chemotherapeutic agents, antibiotics increase sensitivity to sun-sunburn
- Impaired cognition
- Infection-can contaminate a wound
- Lifestyle-tanning, smoking (decreases oxygen supply to tissues, interferes with Vit c absorption necessary for collagen), body piercings, tattoos-risk for infection Nursing actions that limit the impact of the factors that alter skin integrity - correct answer ✔✔1. Anemia (poor 02 supply)-provide diet rich in iron
- Nutrition deficits-provide supplements for vitamin c, protein, zinc, copper
- Drugs (steroids, vasoconstrictors)-additional monitoring
- Smoking-destroys granulation tissue (encourage/educate on cessation)
- Mechanical friction-careful positioning, lifting equipment
- Age-thinning of vascular circulation (protect fragile skin)
- Obesity-Less blood supply in fatty tissue (monitor skin folds)
- Diabetes-decreased oxygen, poor capillary growth, impaired phagocytosis)- increase glycemic control Braden Scale - correct answer ✔✔Pressure ulcers lower the number, higher the risk 4- less than 17 = risk for pressure ulcers List the characteristics used to classify wounds - correct answer ✔✔1. Skin integrity (open and closed wound) -closed (bruise or tissue swelling from fracture) -open (abrasion, laceration, puncture wound, surgical incision, compound fracture)
- Length of time for healing-acute (healing progresses normally) and chronic (delayed healing due to infection, trauma, ischemia, edema)-diabetic ulcers, pressure injury; lingers for months or years
- Level of contamination (CDC) -clean -uninfected, no inflammation, closed, no tracts are entered -clean-contaminated-resp, genital, urinary, alimentary tracts are entered, no evid. of infection -contaminated-open, fresh accidental wounds -dirty-infected-
- Depth of wound-superficial (epidermal-friction, shearing, burning); Partial thickness (epidermis but not through dermis; full thickness (extend into subcutaneous) Wound types - correct answer ✔✔1. intentional-surgical -incision (sharp instrument)
- unintentional-cut, trauma, pressure ulcer -abrasion (scrape of superficial layers) -abscess-pus due to entry of microbe -contusion (bruise) -crushing (compression of tissue-fracture of bone)
-inflammation: edema, erythema, pain, temp elevation, redness, loss of function, migration of WBC's into tissues, microphages engulf bacteria (phagocytosis), clear debris. Form scab on wound with proteins & fibrin to seal wound; release of histamine, bradykinin, prostaglandins; vasodilation & increased permeability of capillaries
- proliferative phase (granulation): days 5- -Fibroblasts enter wound (connective tissue) -collagen synthesis -new blood & lymph vessels form to form granulation tissue -epithelial proliferation & migration-epithelial cells from surrounding tissue seals the wound (epithelialization)
- Maturation phase: epithelialization (remodeling) -2nd/3rd week -continues 3-6 months -formation of scar tissue -contraction of wound (shrinkage) Wound drainage - correct answer ✔✔-serous (clear)-watery, little cellular matter, serum, clean wound -sanguineous (bloody)-damage to capillaries, deep wounds or wounds in vascular areas -serosanguineous-bloody and serous (commonly seen in new wounds) -purulent-thick, malodorous, infected, pus (WBCs, debris, bacteria)-streptococci or staphylocci -purosanguineous-red tinged pus; small vessels have ruptured Factors that lead to pressure ulcers - correct answer ✔✔-poor circulation -reduced oxygen supply in blood (tobacco or anemic) -limited mobility -limited sensation (nerve damage, head injury, stroke, spinal cord injury, diabetes) -poor nutrition -fever -infection
-dehydration -edema -health status -friction -shearing -moisture Signs of a suspected tissue injury - correct answer ✔✔-purple maroonized area of discolored skin or blood filled blister, caused by damage to skin due to pressure or shear -painful, firm, mushy, boggy, warmer, cooler, compared to adjacent tissue -may evolve rapidly to expose additional layers of tissue -harder to detect in patients with dark skin Stage 1 pressure ulcer - correct answer ✔✔-Non Blanching Redness (does not fade when pressed) -painful, firm or soft, warmer or cooler than adjacent tissue -discoloration remains for 30 min after pressure is relieved stage 2 pressure ulcer - correct answer ✔✔-partial thickness skin loss involving epidermis, dermis, or both -open but shallow -red wound bed slough (yellow, green, or tan necrotic tissue) -can be an open or intact serum-filled blister, or shiny or dry shallow ulcer without slough or bruising stage 3 pressure ulcer - correct answer ✔✔-Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon. -goes through epidermis, dermis, subcutaneous tissue but NOT muscle -you may be able to tell its a stage 3 ulcer because it reveals yellow subcutaneous tissue
-use braden scale to identify those at risk -ensure tubing is not causing injury (cannulas behind ears) -manage moisture under folds, sweating, incontinence -optimize nutrition (protein) and hydration -minimize pressure and shearing-use lift equipment, pillows to elevate/reposition Describing drainage - correct answer ✔✔-amount -color -draining -odor Assessing a wound - correct answer ✔✔-Location -size -type -undermining or tunnelling -periwound (examine the skin surrounding the wound) -drainage -pain -nutritional status If client is lying in the same spot for prolonged period - correct answer ✔✔turn at least every 2 hours; client is at increased risk of skin breakdown if area stays red an hour or more after turning; do NOT massage reddened areas of skin; raise heels of feet, keep bed below 30 deg, to relieve pressure on sacrum, buttocks, heels, lift rather than pull clients up in bed If client has decreased sensation - correct answer ✔✔protect skin: make sure client is not lying on tubing or are up against a side rail if client has edema/swelling - correct answer ✔✔elevate the swollen extremity and use compression stockings
if client has Poor circulation or perfusion - correct answer ✔✔avoid tight clothing, shoes, or wraps, use compression stockings if client has constant moisture, lying in urine or stool - correct answer ✔✔keep skin dry and intact if client has Skin that is easily torn or damaged - correct answer ✔✔avoid sliding a person in bed; use draw sheet, place pillow next to side rail if client has diabetes causes delayed wound healing - correct answer ✔✔monitor blood glucose and give medications for diabetes if client has poor nutrition and hydration - correct answer ✔✔eat a healthy diet (protein, vitamin c, zinc, copper) and drink at least 8 glasses of water each day if client has anemia - correct answer ✔✔increase iron in diet (red meat, seafood, poultry, dried fruits, green leafy veggies, beans) If client smokes - correct answer ✔✔program to help client stop smoking if client has obesity - correct answer ✔✔clean under skin folds and pat dry Braden Scale for Predicting Pressure Sore Risk - correct answer ✔✔6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear -min score: 6 -max score: 23 -lower score=higher risk -less than 16 makes a person more at risk Five signs of inflammation - correct answer ✔✔redness, swelling, heat, pain, loss of function
-reddened wound edges Nurse educator should teach which alterations for wound healing by secondary intention? - correct answer ✔✔-stage 3 pressure injury -open burn area Client has wound that is separated with viscera separated - correct answer ✔✔- cover area with saline soaked sterile dressing -position client supine with hips and knees bent client is at risk for developing pressure injury. What actions should the nurse take? - correct answer ✔✔-position head of bed 30 deg -have client sit on gel cushion when sitting in chair The nurse would recognize which client as being particularly susceptible to impaired wound healing?a. a client whose breast reconstruction surgery required numerous incisionsb. A client who is NPO (nothing by mouth) following bowel surgeryc. an obese woman with a history of type 1 diabetesd. a man with a sedentary lifestyle and a long history of cigarette smoking - correct answer ✔✔obese woman A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?a. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.b. Clean the wound from the top to the bottom and from the center to outside.c. Clean the wound in a circular pattern, beginning on the perimeter of the wound.d. Use clean technique to clean the wound. - correct answer ✔✔top to bottom, center to outside 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? a. The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound. b. The client's size limits his activity level. c. Adipose tissue is poorly vascularized. - correct answer ✔✔adipose tissue
A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.1. Cyanosis2. Decreased radial pulse3. Fingers with quick capillary refill4. No finger numbness or tingling5. Warm hand - correct answer ✔✔3,4, The nurse is caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states, "My pain medication is effective, but will this pain ever get better and go away?" Which response is correct?a. "If the pain does not subside by this time tomorrow, you will need to be screened for the development of chronic pain."b. "It is unusual for you to still have severe pain. I will contact your surgeon."c. "If the prescribed analgesics are controlling the pain, we do not worry about the severity of the pain."d. "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." - correct answer ✔✔d 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? a. "Dehiscence is the softening of tissue due to excessive moisture." b. "Dehiscence is a total separation of the wound with protrusion of the viscera through it." c. "Dehiscence is when a wound has partial or total separation of the wound layers." d. "Dehiscence is not anything that you need to worry about." - correct answer ✔✔c The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a. a large wound with considerable tissue loss allowed to heal naturally b. a surgical incision with sutured approximated edges c. a wound healing naturally that becomes infected. d. a wound left open for several days to allow edema to subside - correct answer ✔✔b The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply.1. a 10-year-old client with a surgical incision2. a client who is taking corticosteroid drugs3. an older adult who is confined to bed4. a client who eats a diet high in vitamins A and C5. a client who is obese6. a client with a peripheral vascular disorder - correct answer ✔✔2,3,5,
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?a. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.b. The nurse places the heating pad under the client's neck.c. The nurse uses a safety pin to attach the pad to the bedding.d. The nurse covers the heating pad with a heavy blanket. - correct answer ✔✔a 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?a. lacerationb. avulsionc. incisiond. abrasion - correct answer ✔✔c The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?a. "This is normal tissue."b. "Necrotic tissue is devitalized tissue that must be removed to promote healing."c. "That is called slough, and it will usually fall off."d. "You are seeing undermining, a type of tissue erosion." - correct answer ✔✔b 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?a. "Reinforced adhesive skin closures will hold my wound together until it heals."b. "I will not remove the staples myself."c. "After delivery, I will have sutures in place."d. "I may have staples in place for a number of days." - correct answer ✔✔a 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?a. "I must wait 15 minutes between applications of cold therapy."b. "I should keep this on my ankle until it is numb."c. "I will put a layer of cloth between my skin and the ice pack."d. "I can let this stay on my ankle an hour at a time." - correct answer ✔✔c 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? a. puncture b. contusion c. incision d. avulsion - correct answer ✔✔b.
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? a. Leave the therapy on for 10 more minutes and return to remove it after that time. b. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. c. Assist the client to get out of bed and sit up in a chair for a short while. d. Explain to the client that this is not possible because of the health care provider's prescription. - correct answer ✔✔b A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?a. A child's skin becomes less resistant to injury and infection as the child grows.b. An individual's skin changes little over the life span.c. In children younger than 2 years, the skin is thicker and stronger than in adults.d. An infant's skin and mucous membranes are easily injured and at risk for infection. - correct answer ✔✔d A full-thickness or third-degree burn develops a leathery covering called a(an):a. eschar.b. static.c. abrasion.d. erythema. - correct answer ✔✔a. 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. an otic curetteb. a sterile tongue blade lubricated with water soluble gelc. a small plastic ruler d. a sterile, flexible applicator moistened with saline - correct answer ✔✔d TRUE OR FALSE? A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?a. Use an aquathermia pad during the treatment to create heat and circulate the water.b. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue.c. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles.d. Administer analgesics 30 minutes prior to the treatment to act on pain receptors. - correct answer ✔✔d
a. a client sitting in a chair who slides down b. a client who lies on wrinkled sheets c. a client who must remain on his back for long periods of time d. a client who lifts himself up on his elbows - correct answer ✔✔a A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.1. Use the same swab for both wound sites.2. Insert a swab into the wound.3. Place the swab in the culture tube when done.4. Tap the outside of the culture tube with the swab before placing it in the tube.5. Press and rotate the swab several times over the wound surfaces.6. Touch the swab to the intact skin at the wound edges. - correct answer ✔✔2,3, 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? a. Green beans b. Banana c. Pasta salad d. Fish - correct answer ✔✔d The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a. a wound left open for several days to allow edema to subside b. a wound healing naturally that becomes infected. c. a large wound with considerable tissue loss allowed to heal naturally d. a surgical incision with sutured approximated edges - correct answer ✔✔d. The nurse is using the Braden Scale to determine a client's risk for pressure injuries. What criteria will the nurse assess? Select all that apply.1. friction2. sensory perception3. nutrition4. ability5. age - correct answer ✔✔1- A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?a. If there is contamination of dirt and debrisb. The event leading up to the
traumac. The status of the client's tetanus immunizationd. Staging the wound for assessment - correct answer ✔✔c A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk.For what type of injuries would the nurse be alert?a. Broken left ankle, bruising, and dehydration and elevated thrombocytes b. Soft tissue damage, broken left ankle, concussion, bruising, and abrasionsc. Broken left ankle, concussion, bruising, and abrasionsd. Soft tissue damage, broken left ankle, bruising, and dehydration - correct answer ✔✔a. What intervention should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply.1. client repositioning with a lift2. proper client nutrition3. pressure redistribution support surfaces4. 2-hour turn schedule5. pillow placed under knees6. head of bed positioned at 45 degrees - correct answer ✔✔1- 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?a. Cutting with a sharp instrument with wound edges in close approximation with correct alignment b. Tearing of a structure from its normal positionc. Tearing of the skin and tissue with some type of instrument; tissue not alignedd. Puncture of the skin - correct answer ✔✔b 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? a. Herniation of the woundb. Infection of the woundc. Evisceration of the viscerad. Dehiscence of the wound - correct answer ✔✔d 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?a. use pillows to maintain a side-lying position as neededb. place a foot board on the bedc. elevate the head of the bed 90 degreesd. provide incontinent care every 4 hours as needed - correct answer ✔✔A The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?a. The nurse works outward from the wound in lines parallel to it.b. The nurse swabs the wound from the bottom to the top.c. The nurse swabs the wound with povidone-iodine to fight
d. Use less packing material. - correct answer ✔✔a A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply.1. elevate the head of the bed 90 degrees four times daily2. pull the client up in bed as needed3. turn the client every 2 hours when the client is in bed4. encourage the client to take fluids every 2 hours5. provide incontinent care every 2 hours and as needed - correct answer ✔✔3,4, 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?a. Cleanse the wound after obtaining the wound culture.b. Utilize the culture swab to obtain cultures from multiple sites.c. Stroke the culture swab on surrounding skin first.d. Keep the swab and the inside of the culture tube sterile. - correct answer ✔✔d To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? a. "Have you had any recent illnesses?" b. "Do you experience incontinence?" c. "Do you use any lotions on your skin?" d. "How many meals a day do you eat?" - correct answer ✔✔b Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?a. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain.b. Rotate the swab several times over the wound surface to obtain an adequate specimen.c. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station.d. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. - correct answer ✔✔b A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? a. Administer the prescribed analgesic.
b. Notify the health care provider of the pain. c. Document the pain and vital signs. d. Assess the client's wound and vital signs. - correct answer ✔✔d. The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:a. third degree or full thicknessb. fourth degree or fat layerc. second degree or partial thicknessd. first degree or superficial - correct answer ✔✔c A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? a. The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing.b. The wound is 3 × 5 cm, with yellow tissue covering the entire wound.c. The wound is a 3 × 5-cm blood-filled blister.d. The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. - correct answer ✔✔b A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? a. assessing for impaired blood flow to the area of evisceration. b. applying sterile dressings with normal saline over the protruding organs and tissue c. contacting the surgeon d. monitoring for pallor and mottled appearance of the wound - correct answer ✔✔b 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?a. Desiccationb. Macerationc. Necrosisd. Evisceration - correct answer ✔✔a 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?a. period during which new cells fill and seal a woundb. process by which damaged cells recover and reestablish normal functionc.
