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UNIT TEST 2

June 9, 2024

UNIT TEST 2

CHAPTER 2.

____ 1. The client’s wound has purulent exudate. The nurse knows this exudate occurs when the client has

mild inflammation

severe inflammation

severe inflammation accompanied by infection

minimal capillary damage

____ 2. Which client would be least likely to have slow wound healing?

an older adult

a person who eats a high protein, high carbohydrate diet

a person who is anemic

a person who is taking steroids

____ 3. When is the risk for postoperative hemorrhage the greatest?

first 24 to 48 hours after surgery

3 days to 1 week after surgery

48 to 72 hours after surgery

2 to 3 weeks after surgery

____ 4. The client who is 5 days postoperative coughs hard and the wound opens and the intestines protrude through the wound. The nurse knows that this is called

dehiscence

angiogenesis

evisceration

unintentional wound

____ 5. The client has a red wound. How should this wound be cared for?

It should be protected and kept moist and clean.

It needs debridement.

It needs to be cleansed of purulent exudate and nonviable slough needs to be removed.

It should be left open to the air to dry.

____ 6. The nurse is assessing a wound that involves the epidermis and part of the dermis. This is classified as what type of wound?

superficial

partial thickness

deep superficial

full thickness

____ 7. Which statement is true about obtaining a culture from a wound?

Irrigate the wound with antiseptic before culturing.

Irrigate the wound with normal saline before culturing.

Culture any eschar there may be in the wound.

Culture the edges of the wound.

____ 8. When performing a wet to dry dressing, the nurse should

apply a wet dressing to the wound for 30 minutes, remove the wet dressing, and then apply a dry sterile dressing

apply wet soaks and cover with a dry dressing

irrigate the wound with prescribed irrigant and apply a dry sterile dressing

gently pack the wound with slightly moist gauze and cover with a dry sterile gauze

____ 9. What is the therapeutic effect of applying heat?

decrease inflammation and edema

facilitate clotting and control bleeding

improve blood flow to the area

raise threshold of pain receptors

____ 10. Which of the following is least effective in preventing pressure ulcers?

turn and reposition client every 2 hours

use a draw sheet to lift the client when changing positions

keep the client’s skin clean and dry

massage over bony prominences

____ 11. Elders are at a higher risk of skin tears due to

loss of bone mass

dermal-epidermal junction loss

loss of muscle mass

subcutaneous loss

____ 12. All of the following statements about necrotizing fasciitis are true EXCEPT

it is very rare in occurrence and decreasing in incidence

it spreads along the adipose planes

it is typically caused by beta-hemolytic strep

it is a slowly progressing disease

____ 13. All of the following are acceptable nursing interventions for management of pruritic skin EXCEPT

administration of anti-inflammatory agents as indicated

administration of antihistamines as indicated

use of soothing agents such as oatmeal baths

use of alcohol to prevent infection of the skin

____ 14. The term used to describe the skin becoming over-hydrated with a reduction in tensile strength making it more vulnerable to damage from other forces such as friction is

tunneling

maceration

shearing

sanding

____ 15. In which phase of wound healing is the focus on control of bleeding and establishment of a clean wound bed?

inflammatory phase

maturation phase

proliferative phase

keloid phase

____ 16. Which endocrine disorder has the most negative impact on wound healing?

hypothyroidism

diabetes mellitus

Addison’s disease

diabetes insipidus

____ 17. The client asks the nurse, “I am having a debridement of my leg tomorrow. What does this mean?” What is the most appropriate response by the nurse?

You will be evaluated to see how the wound will respond to medications.

You will be fitted for a dressing to wear permanently on your wound.

You will need to ask the doctor what that means, I’m not really sure.

You will have the dead, or necrotic, tissue removed from your leg. This procedure will help the wound heal.

____ 18. A surface wound involving loss of the epidermis and possible partial dermal loss is called a

laceration

evisceration

abrasion

ecchymosis

____ 19. All of the following should be included in the education plan for a client with diabetes mellitus or neuropathy EXCEPT

check the temperature of the bath or shower with your foot to be sure the water is not too hot

inspect the feet everyday and report any injury or problem to the health care provider

always wear clean socks

never go barefoot, even at home

____ 20. What is the term used to describe a bruise of the soft tissue with no break in the skin surface?

contusion

strain

sprain

dehiscence

____ 21. The client has a urinary tract infection and experiences an episode of urinary incontinence. This is classified as what type of urinary incontinence?

acute

stress

chronic

unstable

____ 22. The client has severe arthritis and is unable to go upstairs quickly to the bathroom located on the second floor. The client is sometimes incontinent. This type of incontinence is classified as

urge incontinence

reflex incontinence

functional incontinence

urethra hypermobility

____ 23. Which is not a cause of colonic constipation?

a diet low in fiber

diverticular disease

dehydration

infectious agents

____ 24. Which is a cause of diarrhea?

overhydration

anticholinergic drug

malabsorption disorder

low-fiber diet

____ 25. Which condition is most likely to cause fecal incontinence in a normally continent individual?

diarrhea

sphincter weakness

ignoring the urge to defecate

eating large meals quickly

____ 26. Which question is best to assess nocturia?

How long can you postpone urination?

How many times do you wake up at night and urinate?

Do you leak urine or lose bladder control?

Do you feel you completely empty your bladder?

____ 27. Which client has stress incontinence?

The client states her bladder empties, but she doesn’t know when it will happen because she has no sensation of fullness or urge to void.

The client states she has a strong urge to void, but usually cannot make it to the toilet in time.

The obese client complains of dribbling urine when she sneezes or bends over.

The client states she urinates small amounts frequently, but examination shows bladder distention.

____ 28. What is the recommended daily allowance for fluids for adults?

10 ml/kg body weight

30 ml/kg body weight

20 ml/kg body weight

50 ml/kg body weight

____ 29. The nurse is teaching a client who has frequent urination associated with urgency about foods that should be avoided. The nurse tells the client to avoid all EXCEPT

water

carbonated drinks

caffeinated beverages

aspartame

____ 30. The nurse is instructing a client about promoting good bowel habits. A high-fiber diet is recommended. The nurse instructs the client to increase fiber gradually to prevent

nausea

peripheral edema

abdominal discomfort and bloating

bowel incontinence

____ 31. Which food should be included on a high-fiber diet?

bread

rice

potatoes

broccoli

____ 32. The nurse is teaching a client who has severe diarrhea with dehydration about oral fluids. Which fluid is contraindicated?

water

iced tea

lemonade

broth

____ 33. The client is receiving an -adrenergic blocking agent for the management of urinary retention secondary to benign prostatic hyperplasia. The nurse should instruct the client to

take the medication early in the day

sit up slowly

take the medication twice a week

reduce fluid intake

____ 34. When inserting a urinary catheter into the male client, the nurse should hold the penis

nearly level with the abdomen

at a 90-degree angle to the body

at a 45-degree angle to the body

so it points toward the chest

____ 35. When performing a urinary catheterization on a female client, how far should the nurse insert the catheter?

1 to 3 inches

1 to 3 inches past the point when urine starts to flow

until the hub of the catheter is at the meatus

until resistance is felt

____ 36. When inserting a urinary drainage catheter, the catheter should be lubricated with

petroleum jelly

lotion

normal saline

water-soluble lubricant

____ 37. How should the nurse position the client who is to receive an enema?

left side-lying with right knee bent

prone

supine

right side-lying

____ 38. Which statement is correct regarding administration of a cleansing enema to an adult?

The temperature of the water should be 115 degrees Fahrenheit.

The enema container should be held 24 inches above the anal opening.

Insert the catheter 8 to 10 inches above the anal opening.

If the client complains of cramping, stop the flow until the feeling passes.

____ 39. Which ostomy will have the most formed drainage? The ostomy located in the

ileum

transverse colon

ascending colon

descending colon

____ 40. An ileal conduit is performed on the client who has a cystectomy. What type of drainage will the client have from the stoma?

formed feces at periodic intervals

intermittent urinary drainage

continuous urine

continuous liquid fecal material

____ 41. All of the following are effective nursing strategies for the management of constipation EXCEPT

removal of hardened or impacted stool by mechanical means

increased dietary fiber

decreased fluid intake

regular pattern of exercise

____ 42. The nurse performs all of the following actions when examining the anus EXCEPT

ask the client to take a breath in and hold it

glove and lubricate a finger and rotate the inserted finger 360 degrees

assess for anal sphincter weakness

document perianal varicosities as hemorrhoids

____ 43. When asking a client if he can postpone urination for 2 hours, the nurse is assessing for

urinary retention

diurnal voiding habits

urinary incontinence

nocturia

____ 44. The last resort treatment for the client with overflow urinary problems is

alpha blockers

repair of cystocele

indwelling catheter

removal of bladder tumor

____ 45. When administering which of the following enemas is the nurse using a hypertonic solution?

kayexalate

soap suds

normal saline

tap water

____ 46. The nurse is assessing a client who has been immobilized for several weeks. What may occur as a result of prolonged immobility?

bone demineralization

increased respiratory excursion

decreased cardiac workload

increased peristalsis

____ 47. The nurse making a home visit observes all of the following. Which is a safety hazard for the client with difficulty in mobility?

wall-to-wall carpet in the bedroom

curio cabinet filled with mementos

scatter rugs on the kitchen floor

night lights in the hall and bathroom

____ 48. When assessing a client’s musculoskeletal status,

warn the client when there may be discomfort

stretch all joints to their maximum limit

know that a 0 rating of muscle tone means weakness

know that a 0 rating on flexibility means total inflexibility

____ 49. Which statement is not correct regarding performing passive range of motion exercises on a client?

The nurse should start at the client’s foot and move to the head.

The head should be rotated 1/4 turn from side to side and then flexed and extended.

The arms should be flexed and extended and adducted and abducted.

Do not flex, extend, rotate, abduct, or adduct a joint if the client complains of discomfort.

____ 50. The nurse is lifting a heavy object. Which action, if performed, is incorrect?

Keep the feet apart.

Pull the object, do not push.

Bend at the knees.

Lift with the leg muscles.

____ 51. Which statement is correct about falls? Most falls

occur during the day

involve wheelchairs

occur in the kitchen or bathroom

involve clients with poor hearing

____ 52. The nurse is to ambulate a client who has an IV in his arm, an indwelling urinary catheter, and a chest tube. What action is appropriate for the nurse to take?

Hold the IV so it is higher than the client’s heart while ambulating.

Empty the urinary drainage tube before ambulating.

Empty the closed chest drainage system before ambulating.

Hold the closed chest drainage system above the client’s chest level while ambulating.

____ 53. When transferring a client from a bed to a wheelchair, the nurse should

raise the height of the bed

position the wheelchair 2 feet from the side of the bed

lock the wheelchair brakes and elevate the foot pedals

pivot the client so the client is facing the wheelchair

____ 54. What is the primary purpose of putting high-top tennis shoes on the immobilized client who is positioned in Fowler’s and supine position?

to help prevent foot drop

to promote comfort

to prevent decubitus formation on the heels

to aid in turning the client

____ 55. Which of the special equipment devices is not primarily used to prevent skin breakdown?

air-filled mattress

sheepskin

egg crate mattress

hand-wrist splints

____ 56. The nurse fits crutches correctly when

the crutch pad is one inch below the axilla

the handgrip is adjusted to allow the client to have elbows bent at 30 degrees

the crutches force the client to stand upright

the handgrip is adjusted to allow the client to have elbows nearly straight

____ 57. The nurse is teaching a client how to walk with crutches using a three-point gait. Which instruction is correct?

move the right crutch forward, then the left foot, followed by the left crutch, and finally the right foot

move the right crutch and the left foot forward together and then the left crutch and the right foot forward together

move the crutches and weak leg forward together, then move the weight-bearing leg forward

move the crutches forward, then swing the legs forward together

____ 58. The nurse is caring for a client who is living at home. The client’s family does everything for the client and does not encourage the client to function independently. This condition is described as

well-adjusted dependence

well-adjusted independence

maladjusted dependence

codependence

____ 59. Moving the extremity laterally and away from the midline of the body is

flexion

adduction

extension

abduction

____ 60. Rotating the forearm laterally at the elbows so the palm of the hand turns laterally to face upward is called

supination

internal rotation

pronation

external rotation

____ 61. Which of the following is not an aerobic exercise?

rowing

bicep curls

walking

jumping rope

____ 62. All of the following are benefits of exercise EXCEPT

decreased energy

improved bone density

lowered cholesterol

normalized glucose tolerance

____ 63. You are teaching a client why immobility has so many negative effects on the body. When talking about the effects of immobility on the gastrointestinal system, you would include all of the following EXCEPT

fecal impaction

stress ulcers

diarrhea

decreased appetite

____ 64. Clients on which type of medications are at highest risk for development of necrosis of the femur head?

phenothiazines

corticosteroids

amphetamines

anticoagulants

____ 65. Abnormally increased convexity of the curvature of the spine is documented as

lordosis

scoliosis

list

kyphosis

____ 66. A client in the face-down position is in which position?

Sims’

dorsal recumbent

lateral

prone

____ 67. When transferring a client from the bed to a chair, the nurse should do all of the following EXCEPT

remove her stethoscope before transfer

ask the client to grab onto her neck

place the wheelchair parallel to the bed and as close as possible

place her thumbs downward to prevent potential wrist injury as she lifts

____ 68. The first step in the process of oxygenation is

ventilation

oxygen transport in the blood

alveolar gas exchange

circulation

____ 69. Which of the following does not stimulate ventilation?

increase in the concentration of hydrogen ions in the blood

increase in the concentration of carbon dioxide in the blood

decrease in blood oxygen concentration

increase in concentration of bicarbonate ions in the blood

____ 70. Where does oxygen/carbon dioxide exchange occur?

bronchioles

trachea

alveoli

nasopharynx

____ 71. What condition may cause a shift to the left of the oxyhemoglobin dissociation curve resulting in less oxygen being available to the tissues?

massive transfusions of banked blood

acidosis

hyperthermia

hypoxia

____ 72. The heartbeat normally originates in which part of the heart?

Purkinje fibers

SA node

AV node

bundle of His

____ 73. Venous return is controlled by which of the following?

muscle pressure and valves preventing backward flow

the heart

precapillary sphincters

blood viscosity and autoregulation

____ 74. Which condition is a restrictive pulmonary disease?

asthma

chronic bronchitis

emphysema

pneumonia

____ 75. A collection of fluid between the pleural layers is called a

pleural effusion

pneumothorax

hemothorax

tension pneumothorax

____ 76. Heart failure is a condition in which the heart

stops beating

is unable to pump enough blood to meet the metabolic needs of the body

beats very slowly

beats very rapidly

____ 77. The utilization of glucose for cellular energy is known as which type of metabolism?

anaerobic

stable

aerobic

unstable

____ 78. When tissue or organs are destroyed as a result of oxygen deprivation, it is known as

an infarction

ischemia

hypoxia

dead space

____ 79. During assessment of the client with pneumonia, the nurse notes a bluish coloration of the skin. The nurse interprets this to mean the client is

in the early stages of a respiratory problem

improving

hypoxic

hyperventilating

____ 80. The nurse is auscultating the chest of a client who is admitted with asthma. What type of adventitious breath sounds is the nurse most likely to hear?

fine crackles

pleural friction rub

stridor

sonorous wheeze

____ 81. The nurse notes the client has green sputum. This is most characteristic of which condition?

asthma

pneumonia

bacterial infection

pulmonary edema

____ 82. Which finding is most consistent with the nursing diagnosis of Ineffective Breathing Pattern?

client states he feels short of breath

shallow breaths

client has difficulty speaking

rales and rhonchi

____ 83. The client with which medical condition is least likely to have a nursing diagnosis of Ineffective Airway Clearance? The client who has

hypertension

Guillain-Barré syndrome

just had major abdominal surgery

scoliosis

____ 84. Interventions to promote airway clearance include all of the following EXCEPT

effective coughing

hydration

postural drainage

oxygen

____ 85. Aminophylline is prescribed for a client who has asthma. The nurse knows the expected action of this drug for this client is to

dilate the bronchi

thin the respiratory secretions

prevent histamine release from mast cells

prevent inflammatory reactions

____ 86. Which statement is true about an endotracheal tube?

An endotracheal tube is used to maintain the tongue away from the posterior oropharynx in the unconscious client.

It is inserted via a surgical procedure.

An endotracheal tube bypasses the upper airway structures.

An opening is made in the trachea below the cricoid cartilage and a semirigid plastic tube is inserted.

____ 87. The nurse should use which solution to clean the inner cannula of a tracheostomy tube?

tap water

alcohol

Betadine

hydrogen peroxide

____ 88. How should the nurse position the client who is to have endotracheal suctioning?

supine

high Fowler’s

Sims’

side-lying

____ 89. When performing nasopharyngeal suctioning, the nurse should use which type of lubricant?

sterile water

water-soluble lubricant

sterile saline

fat-soluble lubricant

____ 90. When performing tracheal suctioning, the nurse should apply suction for how long?

10-15 seconds

not more than 30 seconds

20-30 seconds

30-60 seconds

____ 91. Pursed-lip breathing is prescribed for a client who has obstructive pulmonary disease for which of the following reasons?

It encourages the client to take slow, deep breaths instead of rapid, shallow breaths.

It delivers a volume of air under pressure.

It prevents collapse of the smaller airways.

It increases the amount of oxygen taken into the lungs.

____ 92. When administering oxygen via nasal prongs to a client, the nurse should

apply water-soluble lubricant to the prongs before inserting

positioasal prongs into the client’s nares with curves of prongs pointing toward the floor of the nostrils

tape the cannula tubing to the client’s face

lubricate the prongs with petroleum jelly before inserting

____ 93. Which of the following is not a possible hazard of oxygen administration?

obliteration of the stimulus to breathe in clients with chronic pulmonary disease

atelectasis due to decreased nitrogen

decreased production of surfactant

obstruction of nasal passages

____ 94. How should the nurse position the client who has decreased cardiac output?

semi-Fowler’s

prone

supine

Sims’

____ 95. An adult in a restaurant appears to be choking and is grabbing at his throat. What should you do initially?

Ask the victim, “Are you choking?”

Wrap your arms around the victim’s waist.

Call 911.

Press your fist into the victim’s abdomen with quick, upward thrusts.

____ 96. An adult client is lying on the floor unresponsive. The nurse should initially

start CPR

notify the emergency medical system

assess for respirations

give two slow, full breaths

____ 97. The nurse is caring for a client who has peripheral vascular disease and is experiencing intermittent claudication. What action is most appropriate for the nurse to take to relieve the pain?

Position the client with his legs elevated.

Administer oxygen.

Encourage the client to exercise his extremities during the painful episode.

Administer narcotic analgesics.

____ 98. Which statement is true about pain?

The nurse is the best judge of a client’s pain.

Clients with severe tissue damage will experience more pain than those with less damage.

Most complaints of pain are psychological.

Addiction is unlikely when analgesics are carefully administered and closely monitored.

____ 99. Which type of pain is well localized?

cutaneous

visceral

somatic

referred

____ 100. The client broke his ankle today. The client is experiencing what type of pain?

acute pain

chronic pain

recurrent acute pain

chronic acute pain

____ 101. The client is diagnosed with a neuropathy. What drug is likely to be most effective in treating this type of pain?

morphine

NSAID

codeine

anticonvulsant

____ 102. Which statement is not true about pain?

There are two known endogenous analgesia systems in humans.

Transmission of visceral pain impulses is faster than impulses from cutaneous pain.

Internal organs are very sensitive to distension.

Ischemic pain onsets rapidly in an active muscle.

____ 103. Which statement is true about the gate control theory of pain?

Small-diameter peripheral nerves transmit noxious stimuli to the CNS and large-diameter peripheral nerves carry nonpain information and can inhibit nociceptor transmission in the spinal cord.

Sensations of all types are carried on the same size peripheral nerves. Stimulating nerve fibers with other sensations will block pain.

Pain stimuli are carried by large-diameter peripheral nerves. The gates on these nerves can be closed by administering analgesics.

Both small- and large-diameter peripheral nerves carry pain impulses. Blocking small fibers with other stimuli will reduce the speed of pain impulse transmission.

____ 104. What is the best method to identify the presence and intensity of pain in clients?

vital signs

observation of nonverbal behavior

analysis of seriousness of tissue damage

pain assessment tools and rating scales

____ 105. For which client would the use of a TENS be inappropriate? A client who

had surgery today and has incisional pain

had a leg amputation and has phantom pain

has a demand cardiac pacemaker and has chest pain

has nerve pain from herpes zoster

____ 106. Which of the following is not a principle to use for the care of clients experiencing pain?

Assess the pain.

Treat the contributing factors.

Choose the least invasive route of administration.

Do not use combinations of analgesics.

____ 107. For which client is the rectal route for administering pain medication contraindicated?

4-year-old child

client who is nauseated

client who is immunocompromised

client who has dysphagia

____ 108. Which analgesic would be subject to the ceiling effect?

NSAID

morphine

codeine

hydromorphone hydrochloride (Dilaudid)

____ 109. The behavior of overwhelming involvement with obtaining and using a drug for other than approved medical reasons is called

pseudoaddiction

tolerance

addiction

physical dependence

____ 110. Risk factors predisposing a person to respiratory depression with the use of opioid analgesics include all of the following EXCEPT

renal dysfunction

altered level of consciousness

normal liver function

abdominal distention

____ 111. Which drug would the nurse expect might be prescribed for a client who has neuropathic pain that is described as dull, aching, or throbbing pain?

carbamazepine

corticosteroid

phenytoin

amitriptyline hydrochloride

____ 112. Which statement is true regarding opioid analgesia in the elderly?

Family caregivers tend to under-medicate their relative’s pain.

Cheyne-Stokes respirations are an indication that the opioids should be discontinued.

Drugs have a shorter pain-relief duration.

Opioids usually have a lower peak action.

____ 113. All of the following statements about pain are true EXCEPT

pain is often misunderstood and misjudged

the sensation of pain is the warning of potential tissue damage

pain can be objectively measured by another individual

pain may be absent in people with diabetic neuropathy

____ 114. Mr. L. complains of pain that is well localized in his arm and “burning.” The nurse identifies this as which type of pain?

cutaneous pain

visceral pain

referred pain

neuropathic pain

____ 115. The changing of noxious stimuli in sensory nerve endings to energy impulses is referred to as

modulation

transmission

perception

transduction

____ 116. Which statement about pain and children is true?

Narcotics are more dangerous for children than adults.

Infants feel pain.

Children become accustomed to pain.

Children tolerate pain better than adults.

____ 117. Which type of medication would be most effective in relieving pain due to spinal cord edema?

neuroleptics

tricyclic antidepressants

corticosteroids

anticonvulsants

BANDAGING

Bandages are narrow strips of fabric, gauze, or elastic material used on wounds to aid and promote the healing process. Bandages are used to cover wounded areas, hold dressings in place, and reduce edema. Bandages may also be used to apply pressure or support to a specific area without compromising circulation, alignment, or mobility.

Gauze bandages are readily available in a variety of widths, so the size of the bandage can be chosen to correspond to the size of the wound and body part involved. Another advantage of gauze is that it is porous, which promotes healing by allowing the circulation of air.

Elastic bandages are also available in a variety of widths and have the added advantage of applying more pressure/compression because of their elastic quality. Therefore, they are used more often to pre vent edema on lower extremities.

Fabric bandages are not routinely used. Fabric bandages can be made, however, from many available sources. These can be used in emergency situations.

ASSESSMENT

1. Assess the wound to be covered if a wound is involved. If there is active bleeding, the bleeding must be controlled to prevent hemorrhage and possible hypovolemia. A pressure dressing can be applied using a bandage to hold the pressure compress in place if necessary. A bandage should not be applied to a wound that does not have a dressing over the bleeding area. Immobilizing a joint or broken bone is one of the most important factors in controlling blood loss, and a properly applied bandage can aid in immobilization.

2. Assess the client’s level of consciousness. This is important so that the client can report if the bandage is too tight and is possibly restricting circulation. If the client has a decreased level of consciousness, use extra caution to ascertain that the dressing is not too constricting.

3. Assess the client’s skin integrity, paying special at tention to the presence of edema, ecchymosis, lacerations, abrasions, any bony prominence, and the condition of the skin (dry, cracked, infected, thin). These factors will help determine what bandage products and techniques to use.

4. Assess neurovascular status. Check capillary reﬁll, temperature,and color of the skin in the area surrounding and distal to the bandage. Check motion, sensation, and pulses. These factors will helpdetermine a baseline for future assessments as well as what type of bandaging product or technique to use.

DIAGNOSIS

ü Risk for Fluid Volume Deﬁcit

ü Impaired Skin Integrity

ü Altered Tissue Perfusion, related to wound, skin, and structures distal to area involved

ü Impaired Physical Mobility

ü Pain

PLANNING

Expected Outcomes:

The client does not become hypovolemic, and bleeding is controlled.

The wound is supported and in alignment. The bandage is applied properly, with adequate anchoring and no loose or dangling ends. The client does not experience pain or discomfort from the bandaging.

There is adequate circulation to the wound and distal body parts before, during, and after application of the bandage.

The client does not report any numbness or tingling. The wound heals, without breakdown of skin or neurovascular status.

Equipment Needed:

ü Dressing for wound, if present

ü Bandage, either gauze, elastic, or fabric (emergent situation)

ü Gloves to maintain body ﬂuid precautions if there isthe potential for body ﬂuids

ü Tape or clips to secure bandage

CLIENT EDUCATION NEEDED:

1. It is important that clients understand what the nurse is doing and why the bandage is being applied (to control the bleeding, support the wound/ limb, hold a dressing in place, reduce edema). If clients are part of the process, they will experience less discomfort, will be of more assistance in applying the bandage, and will be more compliant in keeping the bandage in place after the nurse has ﬁnished applying it.

2. The client should be taught the importance of having the bandage smooth to avoid any unwanted constriction.

3. The client needs to understand the importance of reporting any numbness, tingling, or discoloration of skin in the area of the bandage or distal to it.

4. Clients need to understand that they should report any drainage that has soaked through the bandage. Active bleeding needs to be controlled and reported. It is important to maintain a clean wound with less potential for secondary infection.