Deck 36: Skin Integrity and Wound Care

Question 1

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

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

Answer 1

Black

Question 2

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

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

Answer 2

Breast biopsy

Question 3

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months.What does the nurse determine as the significance of the trending of these scores?

A)Trending can only be accurate if the same scale is used.
B)There is a definite trend of low risk for pressure ulcer development.
C)Trending would be more accurate if the same scale was used.
D)The scores indicate opposite risks for pressure ulcer development.

Answer 3

Trending would be more accurate if the same scale was used.

Question 4

After completing a scheduled every-2-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 hyperemia
B)Stage I pressure ulcer
C)Stage II pressure ulcer
D)Stage III pressure ulcer

Question 5

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

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

Question 6

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 edematous and feels boggy.The edges of the wound cup in toward the center.Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

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

Question 7

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)must be certified.
C)is required to ask the client's permission.
D)has to obtain special assessment equipment.

Question 8

A client is prescribed antiembolic stockings.How should the nurse assess the skin on the client's legs?

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

Question 9

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 for this client?

A)Clean-contaminated
B)Contaminated
C)Dirty
D)Infected

Question 10

The UAP reports a small skin tear on the client's forearm that occurred during a routine turn.After assessing the wound the nurse should take which action?

A)Obtain a transparent dressing for the UAP to place on the wound.
B)Request a consult with the wound care nurse.
C)Cleanse the wound and apply a dressing.
D)Tell the UAP to reevaluate the wound in 20 minutes.

Question 11

A client is prescribed steroid medication.When preparing discharge instructions,the nurse should include information about infection control because steroids cause

A)decreased oxygen supply to tissues.
B)suppression of the inflammatory process necessary for healing.
C)a decrease in the amount of nutrients such as glucose in the blood.
D)blood vessel constriction,which impairs waste product removal.

Question 12

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

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

Question 13

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)Materials used in dressing this wound should keep the wound bed moist.
B)The dressing should allow good air circulation through the wound.
C)Dressings should be simple as they will be changed at least every 4 hours.
D)Absorbent material to wick exudates away and support drying should be used.

Question 14

Multiple severely injured clients have arrived in the emergency department.On rapid assessment,the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage.The client is otherwise stable.What action should the nurse take?

A)Place a tourniquet above the wound.
B)Remove the dressing and place direct pressure on the wound.
C)Add an additional dressing to the wound without removing the original.
D)Remove the dressing and replace it with a new sterile dressing.

Question 15

A client's laceration has been closed with tissue adhesive.What instruction should the nurse provide the client about wound healing?

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

Question 16

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

Question 17

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx.Which finding,discovered by the nurse during evaluation,might be implicated in the failure to achieve this outcome?

A)The rubber doughnut pressure relief device was not delivered by central supply.
B)The client's serum albumin increased over the last month.
C)Nurses did not document disinfection of the wound with alcohol with each dressing change.
D)Unlicensed assistive personnel (UAP)followed a right side-back-left side-back turning schedule.

Question 18

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)Keep the head of the client's bed at 30 degrees.
B)Coat the client's back and buttocks with baby powder after bathing.
C)Use a turn sheet lifted by two staff members to move the client in bed.
D)Dust the linens with cornstarch each morning to allow for easier movement.

Question 19

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

Question 20

A client has sustained multiple contusions from a motor vehicle accident.What should the nurse do to prepare for this client's care?

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

Question 21

The nurse is preparing to apply a bandage to a client using the spiral reverse turn.For which body parts should the nurse use this technique when bandaging?
Standard Text: Select all that apply.

A)Finger
B)Forearm
C)Upper leg
D)Lower leg
E)Upper arm

Question 22

A client has a wound that is going to heal through secondary intention.When instructing the client about this wound,the nurse would include which statements?
Standard Text: Select all that apply.

A)Minimal tissue loss.
B)Closure of the wound will occur within 5 days.
C)Healing time will be longer.
D)Potential for scarring is greater.
E)Susceptibility to infection is greater.

Question 23

A client has several dark,thick scars on body locations from previous surgeries and injuries.The nurse realizes this occurs during which phase of wound healing?

A)Exudative
B)Proliferative
C)Inflammatory
D)Maturation

Question 24

The nurse is assessing a client's pressure ulcer.To determine the depth of the ulcer,the nurse should take which action?

A)Measure the width.
B)Measure the length.
C)Insert a sterile swab into the deepest part of the wound.
D)Identify where on the face of a clock the ulcer is located.

Question 25

While changing a client's dressing,the nurse notes thick yellow-green drainage on the gauze.How should the nurse document this wound's drainage?

A)Purulent
B)Serous
C)Sanguineous
D)Serosanguinous

Question 26

A client has a yellow wound with purulent drainage.The nurse identifies what type of wound care as appropriate for this client's wound?
Standard Text: Select all that apply.

A)Cover it with transparent film.
B)Apply a damp-to-damp normal saline dressing.
C)Cover it with a dry dressing.
D)Irrigate the wound.
E)Apply impregnated hydrogel.

Question 27

The nurse documents that a client's postoperative wound is purosanguinous.What did the nurse assess in this client's wound?

A)Water and red blood cells
B)Pus and red blood cells
C)Watery drainage
D)Pus

Question 28

A client sustained several wounds on the legs caused by a fall.On the day after the injuries,the wounds appear red and edematous.The nurse identifies the stage of healing of these wounds as being in which phase?

A)Inflammatory
B)Proliferative
C)Maturation
D)Remodeling

Question 29

During morning care,unlicensed assistive personnel observe a client's abdominal wound dressing become saturated with bright red blood.What should unlicensed assistive personnel do?

A)Reinforce the wound with supplies on the client's bedside table.
B)Document that the bath was completed,and the condition of the dressing.
C)Complete the bath,then report the change to the nurse.
D)Report the dressing changes to the nurse immediately.

Question 30

A client has episodes of bowel and bladder incontinence.When planning care for this client,the nurse would identify which nursing diagnosis as being appropriate?

A)Impaired Skin Integrity
B)Risk for Impaired Skin Integrity
C)Impaired Tissue Integrity
D)Risk for Infection

Question 31

A client asks why a cold pack has been prescribed for an arm injury.What should the nurse explain to the client?
Standard Text: Select all that apply.

A)The application of cold dilates blood vessels.
B)The application of cold constricts blood vessels.
C)The application of cold decreases inflammation.
D)The application of cold reduces localized pain.
E)The application of cold provides a calming,sedative effect.

Question 32

The nurse identifies an older client as being at risk for impaired skin integrity.What did the nurse assess in this client?
Standard Text: Select all that apply.

A)Poor skin turgor.
B)Elevated body temperature.
C)Diminished pain sensation.
D)Thin epidermis.
E)Dry skin.

Question 33

The nurse has applied an aquathermia pad 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)Because this client's thermal tolerance is higher than normal,increasing the temperature is necessary.
B)This client may be experiencing a rebound effect from the application of moist heat.
C)Adaptation of the thermal receptors often results in the decreased sensation of warmth.
D)The aquathermia pad should be replaced with a standard hot pack.

Question 34

The nurse is preparing to apply a moist aquathermia pack to a client's left upper leg.In which order should the nurse prepare and apply this treatment?

A)Use tape or gauze ties to hold the pad in place.
B)Set the desired temperature according to the manufacturer's instructions.
C)Apply the pad to the body part.The treatment is usually continued for 30 minutes.
D)Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer.
E)Cover the pad and plug in the unit.Check for any leaks or malfunctions of the pad before use.