Fundamentals Final Exam - Ch. 32 skin integrity and wound healing actual questions and correct detailed answers 100% verified.

Of the following factors, which would put a client at greatest risk for impaired skin integrity? A. Medication, digoxin B .Moisture C. Decreased sensation D. Dehydration - correct answer C. Decreased sensation Decreased sensation would greatly increase the risk for injury with a tear or break in the skin. This could lead to a delay in seeking treatment due to lack of awareness. The client calls the nurse to the room and states, "Look, my incision is popping open where they did my hip surgery!" The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse's best action is to: A. Notify the surgeon STAT. B. Place a clean, sterile 4 × 4 over the incision and monitor the drainage. C. Wrap an Ace bandage firmly around the area and have the client maintain bedrest. D. Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon - correct answer B. .Place a clean, sterile 4 × 4 over the incision and monitor the drainage. Impaired skin integrity r/t unrelieved prolonged pressure - correct answer pressure injury Localized area of intact skin with non blanchable redness, usually over bony prominence. NOT maroon or purple Which stage does this describe? - correct answer Stage 1 pressure ulcer Involves partial thickness loss of dermis Is open but shallow with a red wound bed no slough Which stage does this describe - correct answer Stage 2 pressure ulcer Deep crater characterized by full thickness skin loss with damage or necrosis of subcutaneous tissue. Adipose tissue is visible Bone or tendon is not visible Which stage does this describe - correct answer Stage 3 pressure ulcer Involves full thickness skin loss with extensive destruction , tissue necrosis Exposed bone and tendon Slough may be present Undermining present Which stage does this descrive - correct answer Stage 4 pressure injury If a pressure injury has an unknown depth what stage is it. It may be completely obscured by slough - correct answer Unstageable pressure ulcer surgical wounds closed by suture, staple, adhesive or any other technique by which surgeon approximates epidermal edges of wound - correct answer primary closure / intention wound is left open due to contamination and increased risk of infection wet to dry dressings heals from inner layer to surface - correct answer secondary closure / intention rather than leaving the wound open, the wound will be partially closed after surgery, and then completely closed 4-7 days after surgery granulated tissue brought together - correct answer tertiary wound closure / intention improper healing of an incision, total or partial separation layers of skin/tissue separate - correct answer dehiscence visceral organs protruding total separation of wound layers - correct answer evisceration clear, watery drainage fluid in a blister - correct answer serous bloody drainage - correct answer sanguineous thin, watery drainage tinged with blood - correct answer serosanguinous thick pus like drainage that is green, yellow, or brown - correct answer purulent applies suction to remove excess fluid from wound bed - correct answer negative pressure wound therapy what can moisture lead to - correct answer maceration (when skin appears wrinkled due to excessive moisture) Contains blood and pus - correct answer Purosanguineous exudate what are the 7 principles of wound healing? - correct answer If the wound bed is: 1. Dry-provide moisture 2. Moist- maintain the moisture 3. Wet- absorb the excess 4. Cool- insulate it (increase perfusion) 5. Infected-disinfect it 6. Necrotic-debride it 7. Stalled (from healing)- provide nutritional support and/or change therapy for cellular deposition / migration, you should try to balance what - correct answer moisture what helps with blood flow in wounds - correct answer warmth is black foam or white foam more protective of healing the wound bed - correct answer black foam If the score on the braden scale is less than ___________, they are at risk for skin breakdown - correct answer 18 used to evaluate if the pressure injury is healing - correct answer PUSH tool what does the VAC in wound vac stand for - correct answer vacuum-assisted closure Is gauze wet to dry or dry to wet - correct answer gauze is wet to dry thin membranes made from polyurethane with water resistant adhesive permeable to vapor and O2 but not most bacteria/water highly elastic, conform to body easy visual inspection useful for superficial wounds or partial thickness wounds with minimal drainage - correct answer transparent film gel-forming polymers with strong film or foam adhesive backing dressings vary in permeability thickness and transparency absorb exudate by swelling into a gel-like mass partial or full thickness wounds - correct answer hydrocolloid varying amounts of water/gel-forming materials available in sheet or amorphous form usually for superficial or partial-thickness wounds with minimal drainage moisture retentive - correct answer hydrogel exudates absorbed into gel mostly in sheets in varying thickness - correct answer foam combines impermeable and absorptive layers nonadherent and adhesive border used for partial or shallow full thickness wounds minimum to heavy exudate changed every 2-3 days - correct answer composite a variation of gauze with petrolatum, zinc, antimicrobials - correct answer impregnated gauze what stage pressure ulcer would you need VAC for - correct answer 3 and 4 nursing diagnoses r/t wound healing - correct answer risk for infection imbalanced nutrition: less than body requirements acute or chronic pain impaired physical mobility impaired skin integrity risk for impaired skin integrity ineffective peripheral tissue perfusion impaired tissue integrity nursing interventions r/t wound healing - correct answer pressure management q2 turns keep skin dry and clean moisture barrier ointment wound care irrigate wound with saline clean dressing