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Skin Infections and Wound Care
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Skin Infections and Wound Care

Created by
@WellReceivedSquirrel7948

Questions and Answers

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?

Stage III.

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)

<p>Monitor your moods after surgery. Depression after surgery is not normal.</p> Signup and view all the answers

What should a client who had a Cesarean section to deliver twins include in their care for the incision?

<p>It is important to keep your sutured incision clean.</p> Signup and view all the answers

What response by the nurse is appropriate when a client questions the potential for curing psoriasis?

<p>You will likely experience periods of increased skin outbreaks and periods of remissions.</p> Signup and view all the answers

Which client is most likely to develop a pressure ulcer from shearing forces?

<p>A client sitting in a chair who slides down.</p> Signup and view all the answers

Which wound is most likely to heal by primary intention?

<p>A surgical incision with sutured approximated edges.</p> Signup and view all the answers

Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply)

<p>A wound that requires wound cleaning and irrigation.</p> Signup and view all the answers

How will the nurse document a wound with well-approximated edges and no signs of infection?

<p>Incision.</p> Signup and view all the answers

Which client would be recognized as particularly susceptible to impaired wound healing?

<p>An obese woman with a history of type 1 diabetes.</p> Signup and view all the answers

What type of dressing should the nurse apply over a client's venous access site?

<p>A transparent film.</p> Signup and view all the answers

What should a student nurse expect to assess in a pressure ulcer staged as 'unstageable'?

<p>The wound is 3 cm × 5 cm with yellow tissue covering the entire wound.</p> Signup and view all the answers

What indicates effective nursing teaching regarding the use of an ice pack?

<p>I will put a layer of cloth between my skin and the ice pack.</p> Signup and view all the answers

What type of injury is anticipated when a student falls onto both knees while running?

<p>Contusion.</p> Signup and view all the answers

What is a characteristic of common skin characteristics in children?

<p>An infant's skin and mucous membranes are easily injured and at risk for infection.</p> Signup and view all the answers

What nursing action would be appropriate to prevent further damage to tissues from blisters around a dressing?

<p>Apply the dressing with a binder.</p> Signup and view all the answers

Why is a large surgical wound healing by secondary intention still open?

<p>Your wound will heal slowly as granulation tissue forms and fills the wound.</p> Signup and view all the answers

What is dehiscence of a wound?

<p>Dehiscence is when a wound has partial or total separation of the wound layers.</p> Signup and view all the answers

Which is not one of the four factors required for adequate skin perfusion?

<p>Local capillary pressure must be lower than external pressure.</p> Signup and view all the answers

What is the primary goal of debridement of a client's coccyx wound?

<p>Removing dead or infected tissue to promote wound healing.</p> Signup and view all the answers

What is the term for an area in a wound that is hollow between the outer surface and the wound bed?

<p>Undermining.</p> Signup and view all the answers

What is the nursing assessment that should be implemented before initiating negative-pressure wound therapy?

<p>Assess the wound for active bleeding.</p> Signup and view all the answers

What is the factor responsible for increased risk of decubitus ulcer when clients are pulled up in bed instead of lifted?

<p>Shearing force.</p> Signup and view all the answers

Which activity should the nurse implement to decrease shearing force on a client with a stage II pressure ulcer?

<p>Support the client from sliding in bed.</p> Signup and view all the answers

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

<p>True</p> Signup and view all the answers

What was determined when a nurse measures the wound of a stab victim using a sterile applicator?

<p>Depth.</p> Signup and view all the answers

What is the appropriate intervention when noticing sutures are encrusted with blood and difficult to pull out during removal?

<p>Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.</p> Signup and view all the answers

What stage of wound healing is recognized for a wound base that is beefy red and bleeds easily?

<p>Proliferation Phase.</p> Signup and view all the answers

How should a nurse document a superficial pressure ulcer that presents clinically as an abrasion, blister, or shallow crater?

<p>Stage II.</p> Signup and view all the answers

What is the correct action taken when applying a heating pad to a client experiencing neck pain?

<p>The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.</p> Signup and view all the answers

Which dressing will the nurse select to cover the site where blood was drawn?

<p>Gauze.</p> Signup and view all the answers

What drainage system would most likely be used for a client with a bacterial infection that needs to be drained?

<p>Penrose drain.</p> Signup and view all the answers

What type of burn is indicated by a pink burn with small blisters?

<p>Second degree or partial thickness.</p> Signup and view all the answers

Which action should the nurse perform to prevent a pressure ulcer for a client on bed rest after a femur fracture?

<p>Use pillows to maintain a side-lying position as needed.</p> Signup and view all the answers

What is the most appropriate food choice to promote wound healing for a confused client?

<p>Fish.</p> Signup and view all the answers

What teaching regarding douching will the nurse provide to a client preparing for a Pap procedure?

<p>Do not douche 24-48 hours before the procedure.</p> Signup and view all the answers

What describes a surgical wound that formed a clean line with little loss of tissue?

<p>Primary intention.</p> Signup and view all the answers

What action should the nurse perform in obtaining a wound culture?

<p>Keep the swab and inside of the culture tube sterile.</p> Signup and view all the answers

How will the nurse categorize a sacral wound with slough, a bad odor, and muscle exposure?

<p>Stage IV.</p> Signup and view all the answers

What is the priority action if a wound culture swab is taken from an uncleaned sacral pressure ulcer?

<p>Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab.</p> Signup and view all the answers

What is the likely intervention in the plan of care for a woman with a labile carbuncle?

<p>Soak in a warm bath for drainage.</p> Signup and view all the answers

What should a nurse assess if a postoperative client states, 'I feel like something has just given away'?

<p>Dehiscence of the wound.</p> Signup and view all the answers

Which drainage types should the nurse document if a watery pink drainage is observed on a dressing during a dressing change?

<p>Serosanguineous.</p> Signup and view all the answers

What describes drainage that is pale pink-yellow, thin, and contains plasma and red cells?

<p>Serosanguineous.</p> Signup and view all the answers

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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Description

This quiz covers essential topics related to skin infections, surgical wound healing, and wound assessment. Learn about common skin infections like impetigo, the stages of pressure ulcers, and effective wound care practices. Test your knowledge on classifications, healing processes, and factors affecting wound recovery.

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