Skin Integrity and Wound Care (36)

Question 1

Your client has a Braden scale score of 17. Which is the appropriate nursing action?

1. ) Assess the client again in 24 hours; the score is within normal limits.
2. ) Implement a turning schedule; the client is at increased risk of skin breakdown.
3. ) Apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown.
4. ) Request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown.

Answer 1

2.) Implement a turning schedule; the client is at increased risk of skin breakdown.

A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate.

Option 1 requires a score above 18 (normal and ongoing assessment is indicated).

Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14.

Option 4, very high risk, is assigned for those with a score of 9 or less.

Question 2

Proper technique for performing a wound culture includes which of the following?

1. ) Cleansing the wound prior to obtaining the specimen
2. ) Swabbing for the specimen in the area with the largest collection of drainage
3. ) Removing crusts or scabs with sterile forceps and then culturing the site beneath
4. ) Waiting 8 hours following a dose of antibiotic to obtain the specimen

Answer 2

1.) Cleansing the wound prior to obtaining the specimen

Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue.

Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride the wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a dose will not significantly affect the concentration of wound organisms.

Question 3

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?

1. ) Alginate
2. ) Dry gauze
3. ) Hydrocolloid
4. ) No dressing is indicated

Answer 3

3.) Hydrocolloid

Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to new granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.

Question 4

Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains the following to the client:

1. ) Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation).
2. ) It will be acceptable to leave the pad in place if the temperature is reduced.
3. ) It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed.
4. ) It will be acceptable to leave the pad in place as long as it is moist heat.

Answer 4

1.) Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation).

The heating pad needs to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect, resulting in vasoconstriction. Lowering the temperature, but still delivering heat—dry or moist—will not prevent the rebound effect.

The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.

Question 5

Which statement, if made by the client or family member, would indicate the need for further teaching?

1. ) “If a skin area gets red but then the red goes away after turning, I should report it to the nurse.”
2. ) “Putting foam pads under my heels or other bony areas can help decrease pressure.”
3. ) “If my father cannot turn himself in bed, I should help him change position every 4 hours.”
4. ) “The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.”

Answer 5

3.) “If my father cannot turn himself in bed, I should help him change position every 4 hours.”

Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires further teaching.

Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported.

It would also be correct to use a foam pad to help relieve pressure.

Question 6

Your client is only comfortable lying on the right or left side (not on the back or stomach). List four potential sites of pressure ulcers you must assess.

1.

2.

3.

4.

Answer 6

Potential pressure ulcer sites for side-lying clients include ankles, knees, trochanters, ilia, shoulders, and ears.

These are important areas to assess. Other answers may also be correct.

Question 7

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is

1. ) Risk for Impaired Skin Integrity.
2. ) Impaired Skin Integrity.
3. ) Impaired Tissue Integrity.
4. ) Risk for Infection.

Answer 7

2.) Impaired Skin Integrity.

This client has an actual impairment of the integrity of the skin due to the rash and the scratching so is no longer “at risk.”

Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues.

Surface excoriation is also not prone to becoming infected.

Question 8

Which of the following are primary risk factors for pressure ulcers? Select all that apply.

1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed

Answer 8

1. Low-protein diet

3. Lengthy surgical procedures

4. Fever

Risk factors for pressure ulcers include low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing.

During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences.

Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity.

Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce the chances of skin breakdown.

A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chances of skin breakdown.

Question 9

Which of the following items are used to perform wound irrigation? Select all that apply.

1. Clean gloves
2. Sterile gloves
3. Refrigerated irrigating solution
4. 60-mL syringe
5. Forceps

Answer 9

1. Clean gloves

2. Sterile gloves

4. 60-mL syringe

To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing.

A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure.

The irrigation fluid should be room or body temperature—certainly not refrigerated.

Forceps may be used to remove or apply a dressing but are not required for irrigation.

Question 10

Which of the following indicates proper use of a triangle arm sling?

1. ) The elbow is kept flexed at 90º or more.
2. ) The knot is placed on either side of the vertebrae of the neck.
3. ) The sling extends to just proximal of the hand.
4. ) The sling is removed every 2 hours to check for circulation and skin integrity.

Answer 10

2.) The knot is placed on either side of the vertebrae of the neck.

The knot of the triangle sling must be kept off the spinal processes because this would be uncomfortable and put unnecessary pressure on the vertebrae.

The elbow should be flexed slightly less than 80° (not >90° as in option 1) so the hand is above the elbow to prevent dependent swelling.

The sling must extend past the wrist in order to support the hand.

Although the sling must be removed to check for circulation and skin integrity, every 2 hours (option 4) is unnecessarily frequent and impractical.