Deck 46: Skin Integrity and Wound Care

Question 1

How should the nurse clean a wound?

A) Go over the wound twice and discard that swab.
B) Move from the outer region of the wound toward the centre.
C) Clean wound from least contaminated to most contaminated area.
D) Use an antiseptic solution followed by a normal saline rinse.

Answer 1

C

Question 2

The nurse recognizes that skin integrity can be compromised when skin is exposed to body fluids.The greatest risk exists for the patient who has exposure to which one of the following fluids?

A) Urine
B) Purulent exudates
C) Pancreatic fluids
D) Serosanguineous drainage

Answer 2

C

Question 3

The patient has a large,deep wound on the sacral region.The nurse correctly packs the wound by doing which one of the following?

A) Filling two-thirds of the wound cavity
B) Leaving saline-soaked folded gauze squares in place
C) Putting the dressing in very tightly
D) Extending only to the surface of the wound

Answer 3

D

Question 4

The nurse determines that the patient's wound may be infected.In order to perform a quantitative swab for wound culture,which of the following actions should the nurse take?

A) Collect the superficial drainage.
B) Collect the culture before cleansing the wound.
C) Obtain a culturette tube and use sterile technique.
D) Use the same technique as for collecting an anaerobic culture.

Question 5

On changing the patient's dressing,the nurse notes that the wound appears to be granulating.Which one of the following is an appropriate noncytotoxic cleansing agent selected by the nurse?

A) Sterile saline
B) Hydrogen peroxide
C) Povidone-iodine (Betadine)
D) Sodium hypochlorite (Dakin's solution)

Question 6

As a result of which of the following causes do pressure ulcers primarily form?

A) Nitrogen buildup in the underlying tissues
B) Prolonged illness or disease
C) Pressure in combination with shear and/or friction
D) Poor nutrition

Question 7

The patient has rheumatoid arthritis,is prone to skin breakdown,and is also somewhat immobile because of arthritic discomfort.Which of the following interventions is the best one for this patient's skin integrity?

A) Having the patient sit up in a chair for four-hour intervals
B) Keeping the head of the bed in a high Fowler's position to increase circulation
C) Repositioning the patient at least every two hours
D) Encouraging the patient to perform pelvic muscle training exercises several times a day

Question 8

Which of the following statements is true for wounds that heal by primary intention?

A) They will probably have minimal scarring.
B) They will probably contain infected tissue.
C) They will probably present with ragged edges.
D) They will probably have portions of missing tissue.

Question 9

A patient comes to the emergency department with a puncture wound.What is the primary danger of a puncture wound?

A) Superficial blood loss
B) Infection and internal bleeding
C) Scarring from secondary intention
D) Difficulty in removing a foreign body

Question 10

The nurse observes thin,watery fluid draining from the left ear of a patient who has sustained a head injury.How would the nurse document this drainage in the patient's chart?

A) Serous
B) Purulent
C) Cerebrospinal fluid
D) Serosanguineous

Question 11

The patient is scheduled for a dressing change.When removing the adhesive tape used to secure the dressing,the nurse should lift the edge and hold the tape in which manner?

A) At a 45-degree angle to the skin surface while pulling away from the dressing
B) At a right angle to the skin surface while pulling toward the dressing
C) At a right angle to the skin surface while pulling away from the dressing
D) Parallel to the skin surface while pulling toward the dressing

Question 12

The nurse is concerned that the patient's abdominal wound is at risk for dehiscence.Which of the following interventions is the best one to prevent this complication?

A) Administering antibiotics to prevent infection
B) Using appropriate sterile technique when changing the dressing
C) Keeping sterile towels and extra dressing supplies near the patient's bed
D) Placing a pillow over the incision site when the patient is deep breathing or coughing

Question 13

A patient has a healing abdominal wound.The wound has minimal exudate and collagen formation.How should the nurse document this wound in the patient's chart?

A) Primary intention
B) Inflammatory phase
C) Proliferative phase
D) Secondary intention

Question 14

The nurse prepares to irrigate the patient's wound.What is the primary purpose of this procedure?

A) To decrease scar formation
B) To cleanse the wound and remove bacteria
C) To improve circulation from the wound
D) To decrease irritation from wound drainage

Question 15

A patient requires wound debridement.The nurse is aware that which of the following statements is correct regarding this procedure?

A) This procedure involves flushing debris from wounds.
B) This procedure involves the removal of nonviable necrotic tissue.
C) Mechanical methods involve direct surgical removal of the eschar layer of the wound.
D) Enzymatic debridement may be implemented independently by the nurse whenever it is required.

Question 16

When using the Braden Scale to predict a patient's pressure sore risk in relation to activity,what score would the nurse use to document for a patient who is confined to a chair?

A) 1
B) 2
C) 3
D) 4

Question 17

When turning a patient,the nurse notices a reddened area on the coccyx.Which of the following skin care interventions should the nurse use on this area?

A) Clean the area, dry it, and add a protective moisturizer.
B) Apply a diluted hydrogen peroxide and water mixture, and use a heat lamp on the area.
C) Soak the area in normal saline solution.
D) Wash the area with an astringent, and paint it with povidone-iodine (Betadine).

Question 18

Which of the following nursing entries is most complete in describing a patient's wound?

A) "Wound appears to be healing well. Dressing dry and intact."
B) "Wound well approximated with minimal drainage."
C) "Drainage size of quarter; wound pink, 4 ´ 4 applied."
D) "Incisional edges approximated without redness or drainage; two 4 ´ 4 applied."

Question 19

The nurse notes that the patient's skin is reddened,with a small intact serum-filled blister.How should the nurse classify this stage of ulcer formation?

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

Question 20

On inspection of the patient's wound,the nurse notes that it appears infected and has a large amount of exudate.Which of the following is an appropriate dressing for the nurse to select based on this wound assessment?

A) Foam
B) Hydrogel
C) Hydrocolloid
D) Transparent film

Question 21

Which of the following is an age-related skin change?

A) Increased collagen
B) Increase in size of hypodermis
C) Flattening of attachment between dermis and epidermis
D) A heightened inflammatory response resulting in increased epithelialization

Question 22

Which nutrient has no known role in wound healing?

A) Vitamin A
B) Vitamin C
C) Vitamin E
D) Zinc

Question 23

Which of the following foods would the nurse recommend in order to increase the patient's intake of vitamin A?

A) Poultry, fish, eggs
B) Tomatoes, potatoes, fruit juice
C) Sweet potatoes, broccoli, liver
D) Oysters, fish, legumes

Question 24

The nurse uses the Braden Scale in the extended care facility to determine the patient's risk for pressure ulcer development.Which score,based on this scale,places the patient at the highest level of risk?

A) <10
B) 10 to 12
C) 13 to 14
D) 15 to 16

Question 25

How should the nurse aim to reduce a patient's risk of developing pressure ulcers?

A) Position the patient directly on the trochanter when the patient is lying on his or her side.
B) Use a doughnut device for the patient when sitting up.
C) Position the patient at a 30-degree lateral turn and limit head elevation to 30 degrees.
D) Massage over bony prominences.

Question 26

What role does protein play in wound healing?

A) Provides fuel for cell energy
B) Promotes collagen synthesis and capillary wall integrity
C) Promotes epithelialization and collagen formation
D) Fibroplasia and angiogenesis

Question 27

The patient is brought into the emergency department with a knife wound.The nurse correctly documents the patient's wound as which type?

A) Contusion wound
B) Clean wound
C) Puncture wound
D) Primary intention wound

Question 28

The patient requires support,and an abdominal binder is ordered.How does the nurse correctly implement the use of the binder?

A) By using it as a replacement for underlying dressings
B) By keeping it loose for patient comfort
C) By having the patient sit or stand when it is applied
D) By making sure the patient has adequate ventilatory capacity