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A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care?
- A. Change the dressing every 6 hours.
- B. Assess the wound bed once a day.
- C. Change the dressing when it is saturated.
- D. Contact the provider when the dressing leaks.
Correct Answer: A
Rationale: Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum debridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.
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A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse?
- A. Recent wound assessment, including size and appearance
- B. Insurance information for billing and coding purposes
- C. Complete health history and physical assessment findings
- D. Resources available to the client for wound care supplies
Correct Answer: A
Rationale: The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.
After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching?
- A. I'll apply cortisone cream to reduce the inflammation.
- B. I'll apply a clean dressing after squeezing out the pus.
- C. I'll keep my arm down at my side to prevent spread.
- D. I'll cleanse the area prior to applying antibiotic cream.
Correct Answer: D
Rationale: Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infection process. Squeezing the lesion may introduce infection to deeper tissues and cause folliculitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?
- A. Draw blood for albumin, prealbumin, and total protein.
- B. Prepare for and assist with obtaining a wound culture.
- C. Place the client in bed and instruct the client to elevate the foot.
- D. Assess the right leg for pulses, skin color, and temperature.
Correct Answer: D
Rationale: A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot is appropriate after assessment of arterial flow to the area.
A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers. Which condition should the nurse suspect?
- A. Scabies
- B. Psoriasis
- C. Eczema
- D. Contact dermatitis
Correct Answer: A
Rationale: White ridges on the skin between the fingers, especially with scratching and rubbing, are characteristic of scabies, a parasitic infestation caused by mites. Psoriasis typically presents with scaly, red patches, eczema with inflamed, itchy skin, and contact dermatitis with localized redness from an allergen or irritant. Scabies is the most likely condition based on the description.
After educating a caregiver of a home care client, a nurse assesses the caregivers understanding. Which statement indicates that the caregiver needs additional education?
- A. I can help him shift his position every hour when he sits in the chair.
- B. If his tailbone is red and tender in the morning, I will massage it with baby oil.
- C. Applying lotion to his arms and legs every evening will decrease dryness.
- D. Drinking a nutritional supplement between meals will help maintain his weight.
Correct Answer: B
Rationale: Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.