c.Damage to the subcutaneous tissue indi-
cates a stage III lesion.
d.A stage III pressure ulcer presents with full-
thickness skin loss.
e.If eschar is present, it may be difficult to
stage a pressure ulcer.
f.The first indication that a pressure ulcer
may be developing is reddening of the skin
over the area under pressure.
9.Which of the following would be appropriate
actions for the nurse to take when cleaning
and dressing a pressure ulcer? (Select all that
apply.)
a.Clean the wound with each dressing
change using aggressive motions to
remove necrotic tissue.
b.Use povidone–iodine or hydrogen peroxide
to irrigate and clean the ulcer.
c.Use whirlpool treatments, if ordered, until
the ulcer is considered clean.
d.Keep the ulcer tissue moist and the sur-
rounding skin dry.
e.Select a dressing that absorbs exudate, if
present, but still maintains a moist envi-
ronment for healing.
f.Pack wound cavities densely with dressing
material to promote tissue healing.
10.Which of the following are effects of the
application of heat in wound care? (Select all
that apply.)
a.The application of heat dilates peripheral
blood vessels.
b.The application of heat decreases tissue
metabolism.
c.The application of heat increases blood
viscosity and capillary permeability.
d.The application of heat reduces muscle
tension and helps relieve pain.
e.Extensive, prolonged heat increases cardiac
output and pulse rate.
f.Extensive, prolonged heat increases blood
pressure.
11.Which of the actions would a nurse be
expected to perform when using cold therapy
during wound care? (Select all that apply.)
a.Apply an ice bag for 1 hour and then re-
move it for about an hour before reapply-
ing it.b.Place a hypothermia blanket on the bed
and cover it with a sheet so the patient’s
skin does not come in direct contact with
the cold blanket.
c.Monitor the patient’s rectal temperature
every 15 minutes and all vital signs every
30 minutes when using a hypothermia
blanket.
d.Change cold compresses frequently, con-
tinuing the application for 1 hour, and re-
peating the application every 2 to 3 hours
as ordered.
e.Avoid wringing out cold compresses to pre-
vent diminishing the effect of the cold.
f.In a home setting, use a bag of frozen veg-
etables (such as peas), if desired, as a sub-
stitute for a cold compress.Prioritization Question
1.Place the following steps to collecting a
wound culture in the order in which they
should be performed.
a.Using aseptic technique, don sterile gloves
and clean wound. Remove sterile gloves.
b.Explain the procedure to patient; gather
equipment; perform hand hygiene.
c.Apply clean dressing to wound.
d.Perform hand hygiene. Remove all
equipment and make patient comfortable.
e.Remove gloves from inside out, and discard
them in plastic waste bag. Perform hand
hygiene.
f.Twist cap to loosen swab in Culturette tube,
or open separate swab and remove cap
from culture tube, keeping inside unconta-
minated. Don clean glove or new sterile
glove, if necessary.
g.Label specimen container appropriately,
attach laboratory requisition to tube with a
rubber band or place tube in plastic bag
with requisition attached; send to lab
within 20 minutes.
h.Carefully insert swab into wound and roll
gently. Use another swab if collecting speci-
men from another site.
i.Place swab in Culturette tube, being careful
not to touch outside of container. Twist cap
to secure; if using Culturette tube, crush
ampule of medium at bottom of tube.CHAPTER 32 SKIN INTEGRITY AND WOUND CARE 197
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:LWBK696-C32_p194-203.qxd 9/3/10 11:53 AM Page 197 Aptara Inc