Deck 48: Skin Integrity and Wound Care

Question 1

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer?

A) Resistance
B) Pressure
C) Weight
D) Stress

Answer 1

Pressure

Question 2

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?

A) The site is hurting.
B) The site is approximated.
C) The site has started to itch.
D) The site has a mass, bluish in color.

Answer 2

The site has a mass, bluish in color.

Question 3

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?

A) Decreased level of consciousness
B) Adequate dietary intake
C) Shortness of breath
D) Muscular pain

Answer 3

Decreased level of consciousness

Question 4

The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing?

A) Eschar
B) Slough
C) Granulation
D) Purulent drainage

Question 5

A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?

A) Protrusion of visceral organs through a wound opening
B) Chronic drainage of fluid through the incision site
C) Report by patient that something has given way
D) Drainage that is odorous and purulent

Question 6

Which nursing observation will indicate the patient is at risk for pressure ulcer formation?

A) The patient has fecal incontinence.
B) The patient ate two thirds of breakfast.
C) The patient has a raised red rash on the right shin.
D) The patient's capillary refill is less than 2 seconds.

Question 7

The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?

A) Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results.
B) Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR).
C) Consult the wound care nurse about the change in status and the potential for infection.
D) Check with the charge nurse about the change in status and the potential for infection.

Question 8

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?

A) Partial-thickness wound repair
B) Full-thickness wound repair
C) Primary intention
D) Tertiary intention

Question 9

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?

A) Disposable measuring tape
B) Cotton-tipped applicator
C) Sterile gloves
D) Halogen light

Question 10

The nurse is caring for a group of patients. Which patient will the nurse see first?

A) A patient with a Stage IV pressure ulcer
B) A patient with a Braden Scale score of 18
C) A patient with appendicitis using a heating pad
D) A patient with an incision that is approximated

Question 11

The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?

A) "I am so weak and tired. I want to feel better."
B) "I am thinking I will be ready to go home early next week."
C) "I am ready for my bath and linen change right now since this is awful."
D) "I am hoping there will be something good for dinner tonight."

Question 12

A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?

A) Vitamin E
B) Potassium
C) Albumin
D) Sodium

Question 13

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

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

Question 14

A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention?

A) Minimal loss of tissue function
B) Permanent dark redness at site
C) Minimal scar tissue
D) Scarring that may be severe

Question 15

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

A) Partial-thickness repair
B) Secondary intention
C) Tertiary intention
D) Primary intention

Question 16

A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?

A) Muscular strength assessment
B) Pulse oximetry assessment
C) Sensation assessment
D) Sleep assessment

Question 17

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?

A) Inspect the wound for foreign bodies.
B) Inspect the wound for bleeding.
C) Determine the size of the wound.
D) Determine the need for a tetanus antitoxin injection.

Question 18

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian?

A) Fat
B) Protein
C) Vitamin E
D) Carbohydrate

Question 19

The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient?

A) Partial-thickness repair
B) Secondary intention
C) Tertiary intention
D) Primary intention

Question 20

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record?

A) Stage I pressure ulcer
B) Healing Stage II pressure ulcer
C) Healing Stage III pressure ulcer
D) Stage III pressure ulcer

Question 21

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk?

A) Use gentle cleansers, and thoroughly dry the skin.
B) Use therapeutic bed and mattress.
C) Use absorbent pads and garments.
D) Use products that hold moisture to the skin.

Question 22

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?

A) At least 3 hours
B) Less than 2 hours
C) No longer than 30 minutes
D) As long as the patient remains comfortable

Question 23

The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first?

A) Offer favorite fluids.
B) Turn the patient every 2 hours.
C) Determine the patient's risk factors.
D) Encourage increased quantities of carbohydrates and fats.

Question 24

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?

A) Place the patient in a 30-degree supine position.
B) Utilize a transfer device to lift the patient.
C) Elevate the head of the bed 45 degrees.
D) Slide the patient into the new position.

Question 25

The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question?

A) Use a low-air-loss therapy unit.
B) Irrigate with Dakin's solution.
C) Apply a hydrogel dressing.
D) Consult a dietitian.

Question 26

The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?

A) 15
B) 17
C) 20
D) 23

Question 27

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

A) Monitor the wound.
B) Document the wound.
C) Debride the wound.
D) Manage drainage from wound.

Question 28

The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?

A) Pressure points
B) Breath sounds
C) Bowel sounds
D) Pulse points

Question 29

The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?

A) Imbalanced nutrition: less than body requirements
B) Ineffective peripheral tissue perfusion
C) Risk for infection
D) Acute pain

Question 30

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan?

A) Readiness for enhanced nutrition
B) Impaired physical mobility
C) Impaired skin integrity
D) Chronic pain

Question 31

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?

A) Turn on the television.
B) Explain the procedure.
C) Tell the patient "Close your eyes."
D) Ask the family to leave the room.

Question 32

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?

A) Explain the risks of immobility to the patient.
B) Turn the patient every 3 hours while in bed.
C) Encourage the patient to sit up in the chair.
D) Provide analgesic medication as ordered.

Question 33

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take next?

A) Call the health care provider; a blockage is present in the tubing.
B) Chart the results on the intake and output flow sheet.
C) Do nothing, as long as the evacuator is compressed.
D) Remove the drain; a drain is no longer needed.

Question 34

The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient?

A) The patient will state what to look for with regard to an infection.
B) The patient's family will demonstrate specific care of the wound site.
C) The patient's family members will wash their hands when visiting the patient.
D) The patient will remain free of odorous or purulent drainage from the wound.

Question 35

A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?

A) A patient with a clean Stage I
B) A patient with a clean Stage II
C) A patient with a clean Stage III
D) A patient with a clean Stage IV

Question 36

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

A) Provide analgesic medications as ordered.
B) Avoid accidentally removing the drain.
C) Don sterile gloves.
D) Gather supplies.

Question 37

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. Which health care team member will the nurse consult?

A) Respiratory therapist
B) Registered dietitian
C) Case manager
D) Chaplain

Question 38

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?

A) Low-air-loss
B) Air-fluidized
C) Lateral rotation
D) Standard mattress

Question 39

The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel?

A) Assessing a surgical patient for risk of pressure ulcers
B) Applying an elastic bandage to a medical-surgical patient
C) Treating a pressure ulcer on the buttocks of a medical patient
D) Implementing negative-pressure wound therapy on a stable patient

Question 40

The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one?
1) Apply sterile gloves.
2) Cover and secure topper dressing.
3) Assess wound and surrounding skin.
4) Moisten gauze with prescribed solution.
5) Gently wring out excess solution and unfold.
6) Loosely pack until all wound surfaces are in contact with gauze.

A) 4, 3, 1, 5, 6, 2
B) 1, 3, 4, 5, 6, 2
C) 4, 1, 3, 5, 6, 2
D) 1, 4, 3, 5, 6, 2

Question 41

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)

A) "Can you easily change your position?"
B) "Do you have sensitivity to heat or cold?"
C) "How often do you need to use the toilet?"
D) "What medications do you take?"
E) "Is movement painful?"
F) "Have you ever fallen?"

Question 42

The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

A) 12
B) 13
C) 20
D) 23

Question 43

The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.)

A) Place moist sterile gauze over the site.
B) Gently place the organs back.
C) Contact the surgical team.
D) Offer a glass of water.
E) Monitor for shock.

Question 44

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description.

Calcium alginate

A)Absorbs drainage through the use of exudate absorbers in the dressing
B)Very soothing to the patient and do not adhere to the wound bed
C)Barrier to external fluids/bacteria but allows wound to "breathe"
D)Manufactured from seaweed and comes in sheet and rope form
E)Oldest and most common absorbent dressing

Question 45

The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included?

A) Allow the solution to flow from the most contaminated to the least contaminated.
B) Scrub vigorously when applying noncytotoxic solution to the skin.
C) Cleanse in a direction from the least contaminated area.
D) Utilize clean gauze and clean gloves to cleanse a site.

Question 46

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description.

Gauze

A)Absorbs drainage through the use of exudate absorbers in the dressing
B)Very soothing to the patient and do not adhere to the wound bed
C)Barrier to external fluids/bacteria but allows wound to "breathe"
D)Manufactured from seaweed and comes in sheet and rope form
E)Oldest and most common absorbent dressing

Question 47

The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.)

A) Hemostasis
B) Maturation
C) Inflammatory
D) Proliferative
E) Reproduction
F) Reestablishment of epidermal layers

Question 48

The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.)

A) The patient's expectations are not being met.
B) Skin is intact with no redness or swelling.
C) Nonblanchable erythema is absent.
D) No injuries to the skin and tissues are evident.
E) Granulation tissue is present.

Question 49

The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. Which is the best explanation for the nurse to use when teaching the patient the reason for the binder?

A) It reduces edema at the surgical site.
B) It secures the dressing in place.
C) It immobilizes the abdomen.
D) It supports the abdomen.

Question 50

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)

A) Vision
B) Hyperemia
C) Induration
D) Blanching
E) Temperature of skin

Question 51

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description.

Transparent

A)Absorbs drainage through the use of exudate absorbers in the dressing
B)Very soothing to the patient and do not adhere to the wound bed
C)Barrier to external fluids/bacteria but allows wound to "breathe"
D)Manufactured from seaweed and comes in sheet and rope form
E)Oldest and most common absorbent dressing

Question 52

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description.

Hydrocolloid

A)Absorbs drainage through the use of exudate absorbers in the dressing
B)Very soothing to the patient and do not adhere to the wound bed
C)Barrier to external fluids/bacteria but allows wound to "breathe"
D)Manufactured from seaweed and comes in sheet and rope form
E)Oldest and most common absorbent dressing

Question 53

The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?

A) Monitor vital signs every 15 minutes.
B) Check pulses in the right foot.
C) Keep the leg dependent.
D) Apply ice.

Question 54

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description.

Hydrogel

A)Absorbs drainage through the use of exudate absorbers in the dressing
B)Very soothing to the patient and do not adhere to the wound bed
C)Barrier to external fluids/bacteria but allows wound to "breathe"
D)Manufactured from seaweed and comes in sheet and rope form
E)Oldest and most common absorbent dressing

Question 55

The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.)

A) Cover exposed wounds.
B) Mark the sites of all abrasions.
C) Assess the condition of current dressings.
D) Inspect the skin for abrasions and edema.
E) Cleanse the area with hydrogen peroxide.
F) Assess the skin at underlying areas for circulatory impairment.