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Chapter 048

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 48: Skin Integrity and Wound Care MULTIPLE CHOICE 1. The nurse determines that the client’s wound may be infected. To perform an aerobic wound culture, the nurse should: 1. Collect the superficial drainage 2. Collect the culture before cleansing the wound 3. Obtain a culturette tube and use sterile technique 4. Use the same technique as for collecting an anaerobic culture ANS: 3 The nurse uses different methods of specimen co
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 4: !kin ntegrity and #ound Care$%T PE C'( CE 1.The nurse determines that the client’s wound may be infected. To perform an aerobic wound culture, the nurse should:1.Collect the superficial drainage2.Collect the culture before cleansing the wound3.Obtain a culturette tube and use sterile techniue!. se the same techniue as for collecting an anaerobic culture#$%:3The nurse uses different methods of specimen collection for aerobic or anaerobic organisms.To collect an aerobic wound culture, the nurse uses a sterile swab from a culturette tube and sterile techniue. The nurse ne&er collects a wound culture sample from old or superficial drainage. 'esident colonies of bacteria from the s(in grow in superficial drainage and may not be the true causati&e organisms of a wound infection. The nurse should clean a wound first with normal saline to remo&e s(in flora before obtaining the culture.)*+:#'+:12--O/:ComprehensionTO0:$ursing 0rocess: 0lanning%C:$C4 test plan designation: 0otential for 'is( 'eduction50otential for #lterations in ody %ystems2.0ressure ulcers form primarily as a result of:1.$itrogen buildup in the underlying tissues2.0rolonged illness or disease3.Tissue ischemia!.0oor nutrition#$%:30ressure is the ma6or cause of pressure ulcer formation. 0rolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. 0rolonged illness or disease and poor nutrition may  place a client at ris( for pressure ulcer de&elopment.)*+:#'+:1278O/:ComprehensionTO0:$ursing 0rocess: #ssessment%C:$C4 test plan designation: 0otential for 'is( 'eduction50otential for #lterations in ody %ystems3.The nurse notes a client’s s(in is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: osby items and deri&ed items 9 288-, 288 by osby, *nc., an affiliate of lse&ier *nc.  Test an( 1.%tage *2.%tage **3.%tage ***!.%tage *;#$%:2This description is consistent with a stage ** pressure ulcer. # stage ** pressure ulcer is defined as partial<thic(ness s(in loss in&ol&ing the epidermis and5or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. # stage *  pressure ulcer is an obser&able pressure<related alteration of intact s(in whose indicators may include changes in one or more of the following: s(in temperature, tissue consistency, and5or sensation. # stage *** pressure ulcer has full<thic(ness s(in loss in&ol&ing damage or necrosis of subcutaneous tissue that may e=tend down to, but not through, underlying fascia. # stage *; pressure ulcer has full<thic(ness s(in loss with e=tensi&e destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.)*+:#'+:1272O/:ComprehensionTO0:$ursing 0rocess: #ssessment%C:$C4 test plan designation: 0otential for 'is( 'eduction50otential for #lterations in ody %ystems!.The client has rheumatoid arthritis, is prone to s(in brea(down, and is also somewhat immobile because of arthritic discomfort. >hich of the following is the best inter&ention for the client’s s(in integrity?1.@a&ing the client sit up in a chair for !<hour inter&als2.Aeeping the head of the bed in a high<+owler’s position to increase circulation3.Aeeping a written schedule of turning and positioning!.ncouraging the client to perform pel&ic muscle training e=ercises se&eral times a day#$%:3The freuency of repositioning should be indi&idualiBed for the client howe&er, clients should be repositioned at least e&ery 2 hours. The #gency for @ealthcare 'esearch and 0olicy D#@'EF guidelines recommend that a written turning and positioning schedule be used. Clients able to sit in a chair should be limited to sitting for 2 hours or less. le&ating the head of the bed to 38 degrees or less will decrease the chance of pressure ulcer de&elopment from shearing forces. 0el&ic muscle training may help pre&ent incontinence, but it is not the best inter&ention for maintaining the client’s s(in integrity.)*+:#'+:138!O/:ComprehensionTO0:$ursing 0rocess: 0lanning%C:$C4 test plan designation: 0otential for 'is( 'eduction50otential for #lterations in ody %ystems. pon changing the client’s dressing, the nurse notes that the wound appears to be granulating. #n appropriate noncytoto=ic cleansing agent selected by the nurse is: osby items and deri&ed items 9 288-, 288 by osby, *nc., an affiliate of lse&ier *nc. !7<2  Test an( 1.%terile saline2.@ydrogen pero=ide3.0o&idone<iodine DetadineF!.%odium hypochlorite D)a(in’s solutionF#$%:10ressure ulcers should be cleansed only with wound cleansers that are not cytoto=ic, suchas normal saline. $ormal saline will not damage or (ill cells, such as fibroblasts and healing tissue. @ydrogen pero=ide, po&idone<iodine DetadineF, and sodium hypochlorite D)a(in’s solutionF are cytoto=ic and therefore should not be used to clean a wound that is granulating.)*+:#'+:138GO/:ComprehensionTO0:$ursing 0rocess: *mplementation%C:$C4 test plan designation: 0otential for 'is( 'eduction50otential for #lterations in ody %ystemsH.# client reuires wound debridement. The nurse is aware that which one of the following statements is correct regarding this procedure?1.*t allows the healthy tissue to regenerate.2.>hen performed by autolytic means, the wound is irrigated.3.echanical methods in&ol&e direct surgical remo&al of the eschar layer of the wound.!.nBymatic debridement may be implemented independently by the nurse whene&er it is reuired.#$%:2'emo&al of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable &isualiBation of the wound bed, and to pro&ide a clean base necessary for healthy tissue toregenerate. #utolytic debridement uses synthetic dressings o&er a wound to allow the eschar to be self<digested by the action of enBymes that are present in wound fluids. The wound is not irrigated. echanical methods include wet<to<dry dressings, wound irrigation, and whirlpool treatments. %urgical debridement in&ol&es direct surgical remo&al of the eschar layer of the wound. nBymatic debridement reuires a health care  pro&ider’s order.)*+:#'+:138GO/:ComprehensionTO0:$ursing 0rocess: *mplementation%C:$C4 test plan designation: 0otential for 'is( 'eduction50otential for #lterations in ody %ystemsG.The nurse prepares to irrigate the client’s wound. The primary reason for this procedure isto:1.)ecrease scar formation2.'emo&e debris from the wound3.*mpro&e circulation from the wound!.)ecrease irritation from wound drainage osby items and deri&ed items 9 288-, 288 by osby, *nc., an affiliate of lse&ier *nc. !7<3  Test an( #$%:2The gentle washing action of the irrigation cleanses a wound of e=udate and debris. The  primary purpose of wound irrigation is not to impro&e circulation, decrease scar formation, or decrease irritation from wound drainage, but to remo&e debris from the wound.)*+:#'+:138GO/:ComprehensionTO0:$ursing 0rocess: *mplementation%C:$C4 test plan designation: 0otential for 'is( 'eduction50otential for #lterations in ody %ystems7.>hen turning a client, the nurse notices a reddened area on the coccy=. >hat s(in care inter&entions should the nurse use on this area?1.Clean the area with mild soap, dry, and add a protecti&e moisturiBer.2.#pply a dilute hydrogen pero=ide and water mi=ture and use a heat lamp to the area.3.%oa( the area in normal saline solution.!.>ash the area with an astringent and paint it with po&idone<iodine DetadineF.#$%:1The s(in should be cleansed and completely dried and a protecti&e moisturiBer applied to (eep the epidermis well lubricated. @ydrogen pero=ide is cytoto=ic and should not be used. # heat lamp is not necessary and would increase the client’s ris( for an accidental  burn. The area should not be soa(ed because this may lead to maceration of the s(in. The area should not be cleansed with an astringent and painted with po&idone<iodine. #n astringent may cause e=cessi&e drying of the tissue, and po&idone<iodine is cytoto=ic.)*+:#'+:138!O/:ComprehensionTO0:$ursing 0rocess: *mplementation%C:$C4 test plan designation: 0otential for 'is( 'eduction50otential for #lterations in ody %ystems-.# client with a large abdominal wound reuires a dressing change e&ery ! hours. The client will be discharged to the home setting, where the dressing care will be continued. >hich of the following is true concerning this client’s wound healing process?1.#n antiseptic agent is best followed with a rinse of sterile saline solution.2.# heat lamp should be used e&ery 2 hours to rid the wound area of contaminants.3.%terile techniue should be emphasiBed to the client and family.!.# dressing co&ering will allow the wound area to remain moist. #$%:! osby items and deri&ed items 9 288-, 288 by osby, *nc., an affiliate of lse&ier *nc. !7<!

Chapter 039

Jul 23, 2017

Chapter 046

Jul 23, 2017
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