Deck 37: Skin Integrity and Wound Care

Question 1

The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide?

A) Wipe the skin with an alcohol-free barrier film agent after cleaning.
B) Apply a petroleum-based cream to the area after cleaning.
C) Keep the client in bed on absorbent pads until the area clears.
D) Wash the area with soap and hot water at every brief change.

Answer 1

Wipe the skin with an alcohol-free barrier film agent after cleaning.

Question 2

The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is oedematous and feels boggy. The edges of the wound cup in toward the centre. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

A) The joint capsule of the hip is visible.
B) The ulcer has thick dark eschar over the top.
C) The crater extends into the subcutaneous tissue
D) There is undermining of adjacent tissues.

Answer 2

The joint capsule of the hip is visible.

Question 3

Which of the following clients would be at the highest risk of a postoperative infection?

A) A 30-year-old smoker.
B) A malnourished 40-year-old.
C) A 90-year-old with cardiac disease.
D) A 50-year-old with HIV.

Answer 3

A 50-year-old with HIV.

Question 4

Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB colour code, which wound care should the nurse plan?

A) Yellow.
B) Black.
C) Red.
D) A combination of all three.

Question 5

After completing a scheduled every-two-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?

A) Reactive hyperaemia.
B) Stage I pressure ulcer.
C) Stage II pressure ulcer.
D) Stage III pressure ulcer.

Question 6

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected?

A) A pus-coated area on the side of the wound.
B) Intact skin at the edge of the wound.
C) Exudate in the bottom of the wound.
D) Clean areas of granulation tissue.

Question 7

The client is routinely taking steroid medications to control lung disease. In the discharge teaching plan the nurse includes information on practising good infection control because steroids cause which of the following?

A) Blood vessel constriction which impairs waste product removal.
B) Suppression of the inflammatory process necessary for healing.
C) Decreased oxygen supply to tissues.
D) Decrease in the amount of nutrients such as glucose in the blood.

Question 8

Match the following terms with its relevant statement in regard to wound healing.
1. Inflammatory phase
2. Proliferative phase
3. Maturation phase
A. Red and oedematous appearance
B. Keloid development
C. Tender fragile tissue

Question 9

The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale, the nurse:

A) should receive specific training.
B) is required to ask the client's permission.
C) must be certified.
D) has to obtain special assessment equipment.

Question 10

The night nurse is assuming care of a cardiac client who wears anti-embolic stockings. How should this nurse manage assessment of the skin on this client's legs?

A) Defer the assessment since the stockings are in place.
B) Review the morning assessment, but don't repeat it unless a problem occurs.
C) Remove the stockings for this assessment.
D) Assess the skin when the client removes the stockings at bedtime.

Question 11

On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first?

A) Position the client in bed with knees bent.
B) Notify the client's surgeon.
C) Pack the wound with non-adherent gauze.
D) Cover the area with a large saline-soaked dressing.

Question 12

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing?

A) Absorbent material to wick exudates away and support drying should be used.
B) Dressings should be simple as they will be changed at least every four hours.
C) Materials used in dressing this wound should keep the wound bed moist.
D) The dressing should allow good air circulation through the wound.

Question 13

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin?

A) Coat the client's back and buttocks with baby powder after bathing.
B) Dust the linens with corn flour each morning to allow for easier movement.
C) Use a lifting device such as a mechanical lifter.
D) Keep the head of the client's bed at 30 degrees.

Question 14

A nurse is assessing a client's wound for possible infection. Wound data that would suggest a severe infection is:

A) serosanguinous exudate, swelling and redness.
B) serosanguinous exudate and heat.
C) haemorrhagic exudate, swelling and redness.
D) purosanguinous exudate and pain.

Question 15

A client has had Braden scores of 18 and 19 and 15 and 17 Norton scores of over the last two months. Is trending of these scores significant?

A) Yes, there is a definite trend of low risk for pressure ulcer development.
B) Somewhat, but trending would be more accurate if the same scale was used.
C) No, trending can only be accurate if the same scale is used.
D) No, the scores indicate opposite risks for pressure ulcer development.

Question 16

The client has a documented stage III pressure ulcer on the right hip. What NANDA-I nursing diagnosis problem statement is most appropriate for use with this client?

A) Impaired Tissue Integrity.
B) Risk for Injury.
C) Impaired Skin Integrity.
D) Altered Tissue Perfusion.

Question 17

The emergency department physician has closed a laceration with tissue adhesive. The nurse provides the client with instruction regarding which type of wound healing?

A) Delayed closure.
B) Primary intention.
C) Secondary healing.
D) Open approximation.

Question 18

An obese patient, who is five days post-abdominal surgery, rings the call bell to tell the nurse that she has 'felt something give' in her abdomen after straining to open her bowels. The nurse's priority is to:

A) check the patient's vital signs.
B) put patient in bed with knees bent.
C) reassure her that it is quite normal.
D) contact the unit manager.

Question 19

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study?

A) Breast biopsy.
B) Gastric resection.
C) Lung resection.
D) Uncomplicated abdominal hysterectomy.

Question 20

The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection. For which category of wound should the receiving nurse plan care?

A) Contaminated.
B) Dirty.
C) Infected.
D) Clean-contamination.

Question 21

The Assistant in Nursing (AIN) reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound, the nurse should:

A) cleanse the wound and apply a hydrogel dressing.
B) request a consult with the wound care nurse.
C) tell the AIN to re-evaluate the wound in 20 minutes.
D) obtain a transparent dressing for the AIN to place on the wound.

Question 22

The nurse has applied a disposable heat pack to a client's back. After 15 minutes of treatment, the client says that the pack no longer is warm and asks the nurse to increase the temperature. How should the nurse evaluate this request?

A) Adaptation of the thermal receptors often results in the decreased sensation of warmth.
B) The heat pack should be replaced with a slightly increased temperature of a thermal application.
C) This client may be experiencing a rebound effect from the heat application.
D) Since this client's thermal tolerance is higher than normal, increasing the temperature is necessary.

Question 24

The nurse is gathering equipment to perform the irrigation of a wound that is being allowed to heal by secondary intention. A sterile syringe, e.g. a ________ size syringe with a catheter of an appropriate size , or an irrigating catheter tip syringe should be obtained.

Question 25

Emergency medical services contacts the emergency department with the report that they are transporting a client who was the victim of a motor vehicle crash. The paramedics report that the client is stable, but has multiple contusions. How should the nurse prepare for this client?

A) Obtain ice packs to apply to the wounds.
B) Organise suture material to close the wounds.
C) Notify the surgical staff that a surgical client will soon be arriving.
D) Request gauze to pack the wounds.

Question 26

The nurse is using an elastic bandage to secure a dressing on an extremity. The bandage should be wrapped in the ________ to ________ direction.

Question 27

Which of the following methods is inappropriate for applying cold therapy?

A) Disposable packs.
B) Sponge bath.
C) Sitz bath.
D) Compresses.