Deck 67: Tissue Integrity

Question 1

The nurse is caring for four clients who have had surgery and knows that which client would benefit the most from the application of a spiral elastic bandage?

A)The client who had a breast reduction.
B)The client who had a hip replacement.
C)The client who had ankle surgery.
D)The client who had a shoulder replacement.

Answer 1

The client who had ankle surgery.

Question 2

The healthcare provider has ordered an elastic bandage to be applied to a wound on a client's femur. The nurse will begin to apply the bandage at which point on the client's leg?

A)The groin
B)The wound itself
C)The knee
D)The hip

Answer 2

The knee

Question 3

The nurse is observing a second nurse who is changing a dressing. While observing the procedure, which would cause the nurse to stop the second nurse and take over the procedure?

A)The second nurse used one swab to clean the wound.
B)The second nurse cleaned the wound from near the wound and then outward.
C)The second nurse kept the forceps tip lower than the forceps handle when cleaning the wound.
D)The second nurse put on clean gloves to begin the wound cleaning process.

Answer 3

The second nurse used one swab to clean the wound.

Question 4

The nurse is completing a skin assessment at the beginning of the shift and will pay particular attention to which areas of the body that are most prone to skin breakdown? Select all that apply.

A)Knees
B)Heels
C)Shoulders
D)Sacrum
E)Toes

Question 5

A client is slated to begin negative-pressure wound therapy tomorrow and the nurse is reinforcing the teaching about this therapy. Which statement by the client requires further teaching by the nurse?

A)"I realize that this device will be hooked up to me almost all day and night."
B)"I believe most people have to use this therapy for about 10 days."
C)"I need to make sure that I continue to eat three balanced meals a day to help my wound heal."
D)"I realize that there will be some pain associated with this therapy but I want my wound to heal."

Question 6

The nurse is preparing to change the dressing and clean the wound of a client who had hip replacement surgery one day ago. The nurse plans to use which solution for the most effective cleaning of the wound?

A)Sterile water
B)Hydrogen peroxide
C)Providone-iodine
D)Normal saline

Question 7

The nurse is preparing to change the dressing of a client who had abdominal surgery 3 days ago. The nurse notes that the incision has purulent drainage and appears very puffy. The client states that the pain level has increased from a 3 to a 7 in the last 24 hours. Which is the nurse's next action in regard to this client's wound?

A)Clean the wound, place a new dressing, and plan to recheck the incision in 4 hours.
B)Contact the client's surgeon after obtaining the client's vital signs.
C)Recognize that this is an expected outcome for a client on the third day after surgery.
D)Culture the wound drainage and redress the wound.

Question 8

The nurse is using wet-to-dry dressing changes to assist in debridement of an open abdominal wound and knows that which step must be performed to ensure that the newly granulated tissue in the wound will not be injured during the dressing changes?

A)Place a heat lamp over the dressing for 15 minutes after the dressing change to prevent chilling the client with the cool dressings.
B)Rewet the dressings with normal saline every 15 minutes to ensure adequate debridement.
C)Soak the dressing with normal saline prior to removal of the packed gauze to prevent damage to the granulating tissue.
D)Premedicate the client 1 hour before the dressing change to improve client cooperation during the dressing change.

Question 9

The wound care nurse has been asked by the healthcare provider to begin negative-pressure wound therapy on a client. Upon assessment of the wound, the nurse notes that the wound still requires a great deal of debridement. Which should the nurse do in this situation?

A)Apply the wound vac because this is the intent of the therapy.
B)Contact the healthcare provider and arrange for debridement of the wound.
C)Apply an autolytic dressing for 24 hours and then apply the wound vac.
D)Place enzymatic debridement product under the black foam and begin the negative-pressure wound therapy.

Question 10

The nurse is caring for 4 clients with wounds and would ask that which client be evaluated further for negative-pressure wound therapy?

A)The client with a burned right arm that requires hydrotherapy three times a day for dressing changes.
B)The client with a wound on the foot that is located near the toes.
C)The client with a wound on the forearm who is malnourished due to anorexia from chemotherapy.
D)The client with an abdominal incision that has not healed and is restricted to bed.

Question 11

The nurse has completed the Braden Risk Assessment Scale on a client who has been diagnosed with a pelvic fracture and has not been able to get out of bed for the last 6 days. This morning the client's score is 10, so the nurse will institute which measures that will help prevent further skin injury? Select all that apply.

A)Bathe the client every day.
B)Use tepid water when bathing the client.
C)Position the client to allow the heels to hang over the bed.
D)Elevate the client's head 45 degrees.
E)Increase the humidity in the client's room.

Question 12

The nurse is preparing to change a dry dressing of a surgical wound and will use which technique to ensure that the wound stays clean during the procedure?

A)The nurse will wear a gown, cap, and shoe covers and will use sterile gloves for the procedure.
B)The nurse will wear a mask and use clean gloves to remove the outer dressing.
C)The nurse does not need to wear any personal protective equipment (PPE)during the procedure.
D)The nurse does not need to wear clean gloves to clean the wound and but should use sterile gloves to reapply the dressing.

Question 13

The nurse is caring for a client with a large venous injury that has just begun to show signs of healing. The nurse contacts the healthcare provider and asks for a change from the chemical method of debridement for which reason?

A)Chemical debridement may damage the tissue that has just begun to heal.
B)Chemical debridement is more painful to venous injuries that have begun to show signs of healing.
C)Chemical debridement is ineffective for venous injuries that have just begun to show signs of healing.
D)Chemical debridement is more useful with arterial injuries than venous injuries.

Question 14

While making rounds, the charge nurse observes a staff nurse cleaning a surgical wound and notes that the staff nurse has cleaned the wound from the top to the bottom of the wound. Which action should the charge nurse take in this situation?

A)Request the staff nurse clean the wound again using a circular motion and cleaning from outside the wound to the wound itself.
B)Make arrangements for the staff nurse to visit the education department for retraining in wound cleaning.
C)Continue with rounds with the knowledge that the staff nurse used the proper cleaning technique.
D)Inform the staff nurse that the charge nurse will be observing the client for signs of infection.

Question 15

The home health nurse is making the first visit to a client who will continue to need sterile dressing changes after abdominal surgery. In assessing the home environment, which must be considered when performing the home dressing change?

A)There is dust on many of the surfaces.
B)The furniture appears worn.
C)There is a cat that is allowed on the furniture.
D)There are dirty dishes on the dining room table.

Question 16

Place the steps for changing a sterile surgical dressing in the appropriate order.

A)Apply clean gloves and remove the old dressing.
B)Apply sterile gloves.
C)Create a sterile field.
D)Assess the incision area for erythema, edema, or drainage.
E)Replace sterile dressing.
F)Clean the incision using sterile saline.

Question 17

The nurse is caring for a client who sustained second-degree burns to both feet. The healthcare provider has ordered debridement of necrotic tissue by mechanical means. The nurse will use which debridement technique that would be the BEST method to complete this task?

A)Wet-to dry dressing changes
B)Hydrotherapy
C)Application of enzymes
D)Application of an occlusive dressing

Question 18

The nurse is caring for an older adult client who was admitted to the hospital after having a stroke. The client was in extremely critical condition on admission to the emergency department and a Braden Risk Assessment Scale was not completed. On the client's fifth day of hospitalization, the nurse notes that the client has developed a stage one pressure injury on the elbow of the side affected by the stroke. Which is the implication of this situation in relation to reimbursement for care of the pressure injury?

A)Medicare will pay for the treatment because it was noticed while the client was still hospitalized.
B)Medicare will not pay for treatment because the pressure injury was not properly documented.
C)Medicare will pay for the treatment because pressure injuries are an expected outcome in a client who has had a stroke.
D)Medicare will not pay for treatment because an initial skin assessment was not completed, so it is assumed that the pressure injury was caused by improper care at the hospital.

Question 19

The nurse has applied an occlusive dressing to a stage 1 pressure injury and knows that this type of dressing assists in debridement of the wound in which way?

A)It mechanically debrides the wound.
B)Enzymes are applied to the wound to remove necrotic tissue.
C)The dressing maintains a moist environment that uses the body's own enzymes.
D)The dressing dries the injury environment, which encourages sloughing of the injured tissue.

Question 20

The nurse is caring for a client who is at high risk for pressure injury formation because of which factors? Select all that apply.

A)The client is often incontinent of urine.
B)The client uses a wheelchair occasionally.
C)The client is vegan.
D)The client has severe arthritis and has trouble being placed in a lateral position.
E)The client attempts to change position every 15 minutes when sitting in a chair.

Question 21

The nurse has just removed sutures on a client and has completed teaching the client about care of the wound at home. Which statement by the client indicates that the client understands the instructions given?

A)"I will leave the dressing in place until I see my doctor in four weeks."
B)"I will only eat soft foods and avoid red meat until my wound is completely healed."
C)"I plan to take a shower every day but not let any soap touch my wound."
D)"I plan to use moisturizing lotion on my wound daily to soften and prevent ugly scar formation."

Question 22

The nurse is caring for a client who is receiving negative-pressure wound therapy for an infected leg wound and is aware that the dressing on this wound must be changed how often?

A)Once a week
B)Every 48 hours
C)Every 24 hours
D)Every 4 hours

Question 23

The nurse is preparing to remove staples from a woman who had a cesarean section 6 days ago and will use which forms of personal protective equipment when performing this task?

A)Sterile gloves, face shield
B)Face shield, gown, clean gloves
C)Gown, sterile gloves, shoe covers
D)Clean gloves

Question 24

The nurse is preparing to remove sutures from a client who sustained a long, deep laceration after a motor vehicle accident and will use what technique to maintain wound stability?

A)The nurse will remove every other suture and reassess the wound for any gaping areas.
B)The nurse will remove all the sutures while holding the edges of the wound together.
C)The nurse will remove the top half of the sutures and return in 1 hour and remove the remaining sutures.
D)The nurse will remove all of the sutures and immediately place a tight dressing over the laceration to ensure that the wound edges stay together.