NUR 222

NUR 222 Exam on Skin & Wounds Integrity A nurse is preparing a diet plan for a client admitted to a wound care unit. After the nurse explains the diet plan to the client, the client asks the reason for an increase in intake of citrus fruits. What should the nurse explain to the client: - Correct Answer-They have antioxidant properties, they help in collagen synthesis, they provide fuel for cell energy The nurse is attending to a client who is immobilized due to stroke. What measures should the nurse take to prevent development of pressure ulcers in the client: - Correct Answer-Keep the client well hydrated, reposition the client every 1-2 hours, place client in a 30-degree lateral position ad avoid pulling on the patient when moving them A nurse is caring for older adult clients in a nursing home. The nurse understands that older adults are susceptible to development of pressure ulcers and other wounds. What makes older adults more vulnerable to developing pressure ulcers: - Correct Answer-diminished inflammatory response, loss of collagen and thinning of muscles When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken: - Correct Answer-Wound after it has first been cleaned with sterile saline The edges of a client's appendectomy incision are approximated, and no drainage is noted. Which type of healing should be applied: - Correct Answer-Primary Intention While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse violated: - Correct Answer-A sterile field becomes contaminated by prolonged exposure to air A nurse is managing wound care for a client with a stage III pressure ulcer on the elbow. The nurse cleans the area and removes all the dead, nonviable tissue from the wound. What term is used to describe this process: - Correct Answer-Debridement A client who has an intravenous line has pain at the access site associated with erythema, edema, red streaks, and a palpable vein. What grade does the nurse assign while entering the phlebitis grade in the client's record: - Correct Answer-Grade 3 Which of the following is an indication for a binder to be placed around a surgical client with a new abdominal wound: - Correct Answer-Reduction of stress on the abdominal incision A client in a rehabilitation clinic is recovering from the loss of a limb in a motor vehicle accident. In addition to wound care and physical therapy, what factors should the nurse assess to help the client recover: - Correct Answer-Family support, behaviors indicating a grief response, the client's point of view of the loss While assessing a patient with major wounds, the nurse finds that the patient has zinc deficiency. Which foods should be included in the patient's diet plan: - Correct Answer-Meat, broccoli, legumes A long-term care facility encourage nurses to assess clients at risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. What tool is the facility using for risk assessment of pressure ulcer development: - Correct Answer-Braden Scale The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which clients would be at increased risk of wound dehiscence: - Correct Answer-A malnourished client An obese client A client with a wound infection A nurse is caring for a client who has a colostomy. When assessing the color of the stoma, which color indicates the stoma is healthy: - Correct Answer-bright pink, brick red Which type of dressing is used for a stage III pressure ulcer: - Correct Answer-Calcium alginate A chronically bed-ridden client has developed pressure ulcers. What nursing interventions are helpful in this situation: - Correct Answer-providing skin care, dressing the ulcer, establishing a programmed turning schedule A nurse administers an analgesic medication to a client with a stage IV pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic: - Correct Answer-30 to 60 minutes after administration A 55-year-old male client underwent a colostomy. Earlier he underwent coronary artery bypass graft (CABG) surgery. The nurse finds the client depressed and weeping. The client expresses that he is fed up with his poor health. He feels that he has become a burden on his family, as he can't go to work now. The nurse concludes that the client is experiencing troubles in the sphere of "Role Performance." Which statement is true about role performance: - Correct Answer-It is the way an individual perceives his or her ability to responsibly carry out significant roles After surgery the client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first: - Correct Answer-Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration The nurse is dressing a wound near the sacrum. Which interventions by the nurse are most beneficial to the patient in this situation: - Correct Answer-Clipping hair around the wound avoiding wrinkles in transparent film cutting the transparent about 5cm beyond wound A senior nurse is teaching a group of students to assess skin changes related to development of pressure ulcers. What should the students keep in mind when assessing dark-skinned clients: - Correct Answer--Blanching is not a conclusive sign in these clients -Differentiate skin color changes with reference to baseline skin tone -Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of clients with dark skin A nurse in a postoperative surgical unit is instructed to perform wound care for a client with an open fracture to his right tibia. What steps are included in wound cleaning: - Correct Answer--clean outward from wound site -when applying antiseptic wipe around the wound edge first -use clean gauze for each revolution around wound circumference A nurse is dressing the surgical wound of a patient in the intensive care unit of a hospital. Which skill should the nurse develop to ensure full dexterity while using gloved hands after applying a sterile gown: - Correct Answer-The nurse should wear gloves with fingers fully extended into them Which factor increases the risk of wound infection: - Correct Answer-Reduced local tissue defenses A nurse educates a patient who has severe wound infection about proper wound care. During the follow-up visit, the nurse observes that the symptoms of the wound infection are resolved. While communicating with the patient, the nurse finds that the patient is following proper interventions. What does the nurse infer from this finding: - Correct Answer-The patient has met the expected outcome On assessment of a chronically bed-ridden client, the nurse suspects the client is at risk for pressure ulcers. What assessment findings help the nurse determine if the client has pressure ulcers: - Correct Answer-warm skin, red lesions Assessment findings consistent with intravenous (IV) fluid infiltration include: - Correct Answer--Edema and pain -Pallor and coolness A nurse assesses an elderly client admitted to the hospital after a fall. What assessment findings could place the client at risk of developing pressure ulcers: - Correct Answer-The client has ~ -urinary incontinence -impaired sensory perception -immobilized due to a leg fracture A client is scheduled for colostomy in two days. The nurse finds the client very anxious, stressed, and saying "How am I going to live with a poop bag for the rest of my life?" What nursing actions would influence the client's self-concept and prepare her for an altered body image: - Correct Answer--Showing the client a video of a healthy functioning body after a colostomy -introducing the client to other clients who have colostomies For a client who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part: - Correct Answer-Ice bag A client with multiple fractures has casts that make it difficult to move voluntarily. A nurse notices red skin in the spinal area that blanches on applying pressure. What measures does the nurse take to decrease the risk of development of pressure ulcers in this client: - Correct Answer--Check the skin around the casts regularly for any signs of impaired skin integrity -Take care to avoid friction injuries during repositioning, bathing, or transferring of the client -Use good hygiene techniques to ensure the client's skin is clean and dry after bowel movements A nurse works in a long-term care unit. Which clients would be at high risk of developing pressure ulcers: - Correct Answer-- client with a spinal cord injury -comatose client -client with urinary incontinence -immobile client with excessive wound drainage