Ch. 29 - Wound Care & Skin Integrity questions and answers 100% verified.

Ch. 29 - Wound Care & Skin Integrity questions and answers 100% verified. A nurse is managing wound care for a patient with a stage III pressure ulcer on the elbow. The nurse cleans the area and removes all the dead, nonviable tissue from the wound. Which term is used to describe this process? Irrigation Debridement Hemostasis Cleansing - correct answers.Debridement Rationale Removal of nonviable necrotic tissue from the wound is called debridement, which can be accomplished chemically, mechanically, autolytically, or surgically. Debridement rids the wound of dead tissues that are ideal for bacterial growth and minimizes the risk of infection. Irrigation involves cleaning the wound with a cleaning solution under pressure to remove bacteria and exudates from the wound bed and maintain moisture. Hemostasis is the control of bleeding from a wound. Cleansing is not used to describe the process of removal of dead tissue from the wound. Which factor increases the risk of wound infection? Absence of necrotic tissue Absence of foreign body in the wound Reduced local tissue defenses Adequate blood supply - correct answers.Reduced local tissue defenses Rationale Reduced local defenses may prevent any counter activity against the microorganisms infecting the wound. Absence of necrotic tissue decreases the risk of infection by improving the blood supply. A foreign body in the wound increases the risk of infection by acting as a port of entry for the microorganisms. Adequate blood supply is important for preventing infection. A long-term care facility encourages nurses to assess patients at risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the facility using for risk assessment of pressure ulcer development? GNASC tool Braden Scale Bates-Jensen tool WOCN scale - correct answers.Braden Scale Rationale The Braden Scale is a widely used tool for risk assessment of pressure ulcer development and is composed of six subscales, which are moisture, sensory perception, activity, mobility, nutrition, and friction or shear. The GNASC tool is used to assess stage I pressure ulcers in patients with dark skin tone. The Bates-Jensen tool is used to assess the wound status. WOCN or the Wound, Ostomy, and Continence Nurses Society does not provide any measurement or assessment tools. The primary health care provider instructs the nurse to apply a bandage on a patient's injured leg. The nurse finds that the patient is anxious. Which nursing action would be taken first in this situation? Explain the procedure to the patient. Notify the primary health care provider. Apply the bandage to the patient immediately. Elevate the patient's leg for 15 minutes before applying the bandage. - correct answers.Explain the procedure to the patient. Rationale Sometimes the patient feels uncomfortable and becomes anxious when a bandage is placed over wound dressings to provide support. In this situation, the nurse should explain the procedure to the patient. This relieves the patient's anxiety and facilitates the patient's cooperation. Anxiety is a normal reaction to a medical procedure. Nurses are accustomed to managing patient anxiety associated with bandaging, and the health care provider does not need to be notified. The patient is anxious; therefore the nurse should not apply the bandage to the patient immediately because the patient may feel uncomfortable. Elevating the leg 15 minutes before applying a bandage is a secondary intervention. It promotes venous return and reduces edema. This would be advisable but does not reduce anxiety. The nurse is caring for a bedridden patient. During the physical examination, the nurse observes that the patient has intact, nonblistered skin with nonblanchable erythema at the sacral area. Which stage of pressure injury does the nurse suspect in the patient? I II III IV - correct answers.I Rationale A pressure ulcer is a localized injury caused by complete or partial obstruction of the blood flow to the soft tissue at the site of the injury. Intact, nonblistered skin with nonblanchable erythema is a manifestation of a stage I pressure ulcer. Symptoms of a stage II pressure ulcer include shallow and superficial pink wounds and intact or ruptured blisters. A full-thickness wound and the presence of undermining or tunneling in the wound are symptoms of a stage III pressure ulcer. A deep wound and infection of the bone are symptoms of a stage IV pressure ulcer. Which nursing intervention would prevent venous stasis in a patient who has a lower limb wound? Raising the bed height to a higher level Elevating the patient's leg for 30 minutes Ensuring the bandage is clean and rolled Exposing the wound for some time before wrapping it - correct answers.Elevating the patient's leg for 30 minutes Rationale Elevation of the leg allows gravity to assist in venous drainage from the peripheral leg veins. Raising the patient's bed may prevent discomfort for the nurse but does not promote venous return. The use of a clean and rolled bandage helps decrease the spread of microorganisms, and the rolled bandage facilitates easy application. Exposing the wound helps position the wounded limb properly before applying the bandage. After surgery the patient 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? Allow the area to be exposed to air until all drainage has stopped. Place several cold packs over the area, protecting the skin around the wound. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly. - correct answers.Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. Rationale If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist. The area should not be exposed to air as this can cause damage or death to the exposed bowel. Cold packs should not be placed over the area as the area needs to be kept moist and clean. A binder should not be placed over the area, and the patient should remain in bed and taken to surgery immediately to repair the damage; this is not a minor opening. Which stage of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and pain? I II III IV - correct answers.I Rationale A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area. A partial-thickness wound that involves the epidermis and/or dermis but does not extend below the level of the dermis is called a stage II pressure injury. It is shallow and superficial, with a pink wound bed. Intact or ruptured blisters that are the result of pressure also are considered to be stage II pressure injuries. Stage III pressure injuries are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Another full-thickness wound is a stage IV pressure injury. This wound is deeper than a stage III pressure injury and involves exposure of muscle, bone, or connective tissue (such as tendons or cartilage). Which process is described as the removal of devitalized tissue from a wound? Debridement