Deck 37: Skin Integrity and Wound Care

Question 1

A patient is wearing an abdominal binder after abdominal surgery.What does the nurse need to assess and document about the patient?

A) Neurological response
B) Respiratory status
C) Lymphatic status
D) Genitourinary response

Answer 1

Respiratory status

Question 2

A patient who has undergone a colectomy is demonstrating wound healing.The nurse correctly identifies the wound phase characterized by synthesis of collagen fibers as which of the following?

A) Proliferative phase
B) Inflammation phase
C) Hemostasis phase
D) Secondary intention phase

Answer 2

Proliferative phase

Question 3

A patient is being seen in the Emergency Department for a puncture wound on the foot.The patient was walking in a construction site,but is unsure what caused the injury.During the initial assessment the nurse determines if the patient has received a tetanus toxoid injection within which time frame?

A) Within the past year
B) Within the last 3 years
C) Within the last 5 years
D) Within the last 10 years

Answer 3

Within the last 10 years

Question 4

Which therapy should the nurse choose that will improve a patient's circulation,relieve edema,and promote concentration of pus and drainage?

A) Warm soaks
B) Warm moist compresses
C) Sitz baths
D) Cold moist compresses

Question 5

An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework.During a bath,the assistive nursing personnel noticed that there was a large blister on the patient's right heel.The patient denies knowledge of having injured self.It was reported to the nurse who correctly documented it as what stage of a pressure ulcer?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Question 6

Assistive personnel ask the nurse the differences between wound healing by primary and secondary intention.The nurse's best response is that healing by primary intention occurs when the skin edges:

A) are approximated.
B) overlap each other.
C) appear slightly red and moist.
D) cannot come together.

Question 7

The student nurse asks a nursing assistive personnel (NAP)to help move a patient up in bed.The student nurse instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation?

A) Friction
B) Shear
C) Moisture
D) Tunneling

Question 8

A patient's draining wound is pale and watery with a combination of plasma and red cells.How should the nurse document this finding?

A) Serous drainage
B) Purulent drainage
C) Sanguineous drainage
D) Serosanguineous drainage

Question 9

The primary health care provider has ordered the patient to wear an elastic bandage to the left ankle owing to a severe strain.The nurse has instructed the patient on proper application of the elastic bandage.Which statement indicates the patient needs more teaching?

A) "I need to wrap the bandage toward my toes."
B) "I need to make sure the bandage is smooth."
C) "I need to watch my toes for swelling and feeling cold."
D) "I need to take the bandage off and call the physician if I experience increased pain."

Question 10

The nurse is preparing to change a large wound dressing on the patient's buttock.Which intervention should the nurse address first?

A) Inspect the dressing for drainage.
B) Medicate appropriately before performing the dressing change.
C) Observe wound edges and if staples or sutures are intact.
D) Assess the insertion site of the drain(s).

Question 11

An elderly patient is admitted to the hospital for a bowel obstruction.The patient is immobile and the nurse notices that there is a reddened area on the right heel.When the nurse presses on the area it does not turn lighter in color.How should the nurse document the tissue condition?

A) Reactive hyperemia
B) Blanchable hyperemia
C) Nonblanchable hyperemia
D) Tissue ischemia

Question 12

An elderly patient who resides in a nursing home is suffering from a respiratory infection.During the illness,the patient has become incontinent of both urine and stool.The nursing staff used a special cleanser on the perineum,put a moisture barrier on the exposed area,and used absorbent briefs to prevent the skin from becoming soft because of the moisture.What was the staff trying to prevent?

A) Maceration
B) Dehiscence
C) Evisceration
D) Debridement

Question 13

A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus.The admitting nurse notes that an area of redness on the right malleolus is nonblanchable.The nurse correctly identifies this pressure ulcer at what stage?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Question 14

A patient is admitted to the hospital with a pressure ulcer on the sacrum.The wound is open with exposed bone.The nurse should document this pressure ulcer at what stage?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Question 15

A postoperative patient visits the ambulatory care clinic complaining of just "not feeling well." The patient has an elevated temperature.Which assessment finding should indicate to the nurse that the wound has become infected?

A) Negative culture
B) No odor
C) Presence of fluid around the edges
D) Purulent drainage coming from the incision area

Question 16

A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan.The admitting diagnosis is failure-to-thrive.On admission,the patient was found to have a wound on the right scapula.The nurse noted full-thickness tissue loss with tunneling,but did not note any bone,tendon,or muscle.This was correctly identified as what stage of a pressure ulcer?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Question 17

A surgical wound requires a hydrogel dressing.What is the primary advantage of a hydrogel dressing?

A) It provides an absorbent to collect wound drainage.
B) It provides a negative pressure to promote healing.
C) It provides protection from the external environment.
D) It provides moisture needed for wound healing.

Question 18

The nurse is caring for a patient with a necrotic hip wound.Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?

A) Dry gauze
B) Transparent film
C) Hydrogel
D) Hydrocolloid

Question 19

Which patient is best suited for heat therapy?

A) A patient with low back pain
B) A patient with suspected appendicitis
C) A patient with first-degree burn
D) A patient with active bleeding

Question 20

An elderly patient has been admitted to the hospital for pneumonia.Which factor could put this patient at risk for a pressure ulcer?

A) A diet low in protein
B) Braden Scale results of 22
C) Primary health care provider orders that read "activity as tolerated"
D) Being repositioned every 2 hours

Question 21

A postoperative abdominal surgery patient has been admitted to the surgical floor.The nurse is aware that wound healing is delayed owing to complications.Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)

A) Dehiscence
B) Evisceration
C) Erythema and edema at the suture site
D) Hemostasis
E) Hemorrhage

Question 22

On admission a patient is noted to have an alteration in skin integrity on the right heel.The nurse uses the Braden Scale.Which areas will the nurse assess when using this scale? (Select all that apply.)

A) Mobility
B) Nutrition
C) Infection
D) Friction and shear
E) Sensory perception

Question 23

When a patient has full-thickness loss but the depth is unknown,how should the nurse classify this pressure ulcer?

A) Stage/Category III
B) Unstageable
C) Suspected deep tissue injury
D) Stage/Category IV

Question 24

A pre-teen quadriplegic patient was admitted with pressure ulcers to both ankles.The nurse should assess which parameters for a wound assessment? (Select all that apply.)

A) Size
B) Viable versus nonviable tissue
C) Tissue type involvement
D) Preventive measures
E) Anatomical location

Question 25

A patient's full-thickness wound is establishing a clean wound bed and obtaining bacterial balance.This patient is in which phase of wound healing?

A) Hemostasis phase
B) Proliferative phase
C) Inflammation phase
D) Remodeling phase