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Questions and Answers
A skin infection caused by beta-hemolytic streptococci common in children is?
A skin infection caused by beta-hemolytic streptococci common in children is?
impetigo.
Which stage should the nurse assign to a pressure ulcer on a client's coccyx area measuring 2 cm × 5 cm with yellow slough and visible subcutaneous fat?
Which stage should the nurse assign to a pressure ulcer on a client's coccyx area measuring 2 cm × 5 cm with yellow slough and visible subcutaneous fat?
Stage III.
What is a characteristic of healing of a minor surgical wound by first intention?
What is a characteristic of healing of a minor surgical wound by first intention?
Very little scar tissue will form.
What education will the nurse provide to an older adult client about self-care at home after surgery? (Select all that apply)
What education will the nurse provide to an older adult client about self-care at home after surgery? (Select all that apply)
What should a client who had a Cesarean section to deliver twins include in their care for the incision?
What should a client who had a Cesarean section to deliver twins include in their care for the incision?
What response by the nurse is appropriate when a client questions the potential for curing psoriasis?
What response by the nurse is appropriate when a client questions the potential for curing psoriasis?
Which client is most likely to develop a pressure ulcer from shearing forces?
Which client is most likely to develop a pressure ulcer from shearing forces?
Which wound is most likely to heal by primary intention?
Which wound is most likely to heal by primary intention?
Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply)
Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply)
How will the nurse document a wound with well-approximated edges and no signs of infection?
How will the nurse document a wound with well-approximated edges and no signs of infection?
Which client would be recognized as particularly susceptible to impaired wound healing?
Which client would be recognized as particularly susceptible to impaired wound healing?
What type of dressing should the nurse apply over a client's venous access site?
What type of dressing should the nurse apply over a client's venous access site?
What should a student nurse expect to assess in a pressure ulcer staged as 'unstageable'?
What should a student nurse expect to assess in a pressure ulcer staged as 'unstageable'?
What indicates effective nursing teaching regarding the use of an ice pack?
What indicates effective nursing teaching regarding the use of an ice pack?
What type of injury is anticipated when a student falls onto both knees while running?
What type of injury is anticipated when a student falls onto both knees while running?
What is a characteristic of common skin characteristics in children?
What is a characteristic of common skin characteristics in children?
What nursing action would be appropriate to prevent further damage to tissues from blisters around a dressing?
What nursing action would be appropriate to prevent further damage to tissues from blisters around a dressing?
Why is a large surgical wound healing by secondary intention still open?
Why is a large surgical wound healing by secondary intention still open?
What is dehiscence of a wound?
What is dehiscence of a wound?
Which is not one of the four factors required for adequate skin perfusion?
Which is not one of the four factors required for adequate skin perfusion?
What is the primary goal of debridement of a client's coccyx wound?
What is the primary goal of debridement of a client's coccyx wound?
What is the term for an area in a wound that is hollow between the outer surface and the wound bed?
What is the term for an area in a wound that is hollow between the outer surface and the wound bed?
What is the nursing assessment that should be implemented before initiating negative-pressure wound therapy?
What is the nursing assessment that should be implemented before initiating negative-pressure wound therapy?
What is the factor responsible for increased risk of decubitus ulcer when clients are pulled up in bed instead of lifted?
What is the factor responsible for increased risk of decubitus ulcer when clients are pulled up in bed instead of lifted?
Which activity should the nurse implement to decrease shearing force on a client with a stage II pressure ulcer?
Which activity should the nurse implement to decrease shearing force on a client with a stage II pressure ulcer?
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
What was determined when a nurse measures the wound of a stab victim using a sterile applicator?
What was determined when a nurse measures the wound of a stab victim using a sterile applicator?
What is the appropriate intervention when noticing sutures are encrusted with blood and difficult to pull out during removal?
What is the appropriate intervention when noticing sutures are encrusted with blood and difficult to pull out during removal?
What stage of wound healing is recognized for a wound base that is beefy red and bleeds easily?
What stage of wound healing is recognized for a wound base that is beefy red and bleeds easily?
How should a nurse document a superficial pressure ulcer that presents clinically as an abrasion, blister, or shallow crater?
How should a nurse document a superficial pressure ulcer that presents clinically as an abrasion, blister, or shallow crater?
What is the correct action taken when applying a heating pad to a client experiencing neck pain?
What is the correct action taken when applying a heating pad to a client experiencing neck pain?
Which dressing will the nurse select to cover the site where blood was drawn?
Which dressing will the nurse select to cover the site where blood was drawn?
What drainage system would most likely be used for a client with a bacterial infection that needs to be drained?
What drainage system would most likely be used for a client with a bacterial infection that needs to be drained?
What type of burn is indicated by a pink burn with small blisters?
What type of burn is indicated by a pink burn with small blisters?
Which action should the nurse perform to prevent a pressure ulcer for a client on bed rest after a femur fracture?
Which action should the nurse perform to prevent a pressure ulcer for a client on bed rest after a femur fracture?
What is the most appropriate food choice to promote wound healing for a confused client?
What is the most appropriate food choice to promote wound healing for a confused client?
What teaching regarding douching will the nurse provide to a client preparing for a Pap procedure?
What teaching regarding douching will the nurse provide to a client preparing for a Pap procedure?
What describes a surgical wound that formed a clean line with little loss of tissue?
What describes a surgical wound that formed a clean line with little loss of tissue?
What action should the nurse perform in obtaining a wound culture?
What action should the nurse perform in obtaining a wound culture?
How will the nurse categorize a sacral wound with slough, a bad odor, and muscle exposure?
How will the nurse categorize a sacral wound with slough, a bad odor, and muscle exposure?
What is the priority action if a wound culture swab is taken from an uncleaned sacral pressure ulcer?
What is the priority action if a wound culture swab is taken from an uncleaned sacral pressure ulcer?
What is the likely intervention in the plan of care for a woman with a labile carbuncle?
What is the likely intervention in the plan of care for a woman with a labile carbuncle?
What should a nurse assess if a postoperative client states, 'I feel like something has just given away'?
What should a nurse assess if a postoperative client states, 'I feel like something has just given away'?
Which drainage types should the nurse document if a watery pink drainage is observed on a dressing during a dressing change?
Which drainage types should the nurse document if a watery pink drainage is observed on a dressing during a dressing change?
What describes drainage that is pale pink-yellow, thin, and contains plasma and red cells?
What describes drainage that is pale pink-yellow, thin, and contains plasma and red cells?
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Study Notes
Skin Infections and Wound Care
- Impetigo is a skin infection caused by beta-hemolytic streptococci, particularly common in children.
- Stage III pressure ulcers involve the loss of skin layers, with subcutaneous fat visible, and may show a yellow slough.
Surgical Wound Healing
- First-intention healing results in minimal scar tissue formation.
- Older adults may experience delayed healing due to age, nutrition, and prior sun exposure.
- Proper post-surgical self-care includes monitoring moods and maintaining a nutritious diet.
Wound Assessment and Treatment
- A surgical incision with well-approximated edges signifies proper healing.
- Clients at risk for impaired wound healing include those who are obese or have chronic conditions like diabetes.
- Normal healing processes involve the formation of granulation tissue; delays may occur without proper care.
Classification of Wounds
- The RYB classification system categorizes wounds based on color; yellow wounds require cleaning and management of oozing.
- Undermining refers to hollow areas beneath wound surfaces; a common concern in stage IV pressure ulcers.
Pressure Ulcers
- Shearing forces, such as sliding in bed, contribute significantly to pressure ulcer development.
- Stage II pressure ulcers typically present as abrasions or shallow craters.
- Use of pillows can help maintain position and reduce pressure during bed rest.
Drainage and Dressing Types
- A Penrose drain is commonly used for draining abscesses; it exits the skin through a stab wound.
- Transparent film dressings are best for venous access sites, while gauze is used for blood sample sites.
Postoperative Care
- Signs of dehiscence include sudden feelings of separation in the surgical site; immediate assessment is required.
- Serosanguineous drainage, which appears watery pink, is common in healing wounds.
Burn and Skin Conditions
- Second-degree burns are characterized by pink skin with blisters; they affect the epidermis and part of the dermis.
- Psoriasis is a chronic condition that tends to have fluctuating periods of flare-ups and remission.
General Best Practices
- Always clean wounds with a nonantimicrobial cleanser prior to obtaining cultures to ensure accurate results.
- Nutritional support is essential; fish is particularly beneficial for wound healing due to its protein and omega-3 fatty acid content.
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