Deck 48: Skin Integrity and Wound Care

Question 1

Following a head injury,the client has thin drainage coming from the left ear.The nurse describes this drainage as:
1) Serous
2) Purulent
3) Cerebrospinal fluid
4) Serosanguineous

Answer 1

1
Serous drainage is clear,watery plasma.Purulent drainage is thick,yellow,green,tan,or brown.Drainage must be tested to determine if it is cerebrospinal fluid.The nurse should describe the drainage by its appearance (i.e. ,serous).Serosanguineous drainage is pale,red,and watery,a mixture of clear and red fluid.

Question 2

Upon changing the client's dressing,the nurse notes that the wound appears to be granulating.An appropriate noncytotoxic cleansing agent selected by the nurse is:
1) Sterile saline
2) Hydrogen peroxide
3) Povidone-iodine (Betadine)
4) Sodium hypochlorite (Dakin's solution)

Answer 2

1
Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic,such as normal saline.Normal saline will not damage or kill cells,such as fibroblasts and healing tissue.Hydrogen peroxide,povidone-iodine (Betadine),and sodium hypochlorite (Dakin's solution)are cytotoxic and therefore should not be used to clean a wound that is granulating.

Question 3

Upon inspection of the client's wound,the nurse notes that it appears infected and has a large amount of exudate.An appropriate dressing for the nurse to select based on the wound assessment is:
1) Foam
2) Hydrogel
3) Hydrocolloid
4) Transparent film

Answer 3

1
A foam dressing absorbs exudate and debris while maintaining a moist environment.Topical agents,such as antibiotic ointment,may also be used with a foam dressing.This would be the most appropriate type of dressing for this wound.A hydrogel dressing provides moisture to a clean granular wound.A hydrocolloid dressing interacts with the wound fluid to provide a moist environment.Transparent film protects from friction injury and may be left in place up to 7 days.

Question 4

A client requires wound debridement.The nurse is aware that which one of the following statements is correct regarding this procedure?
1) It allows the healthy tissue to regenerate.
2) When performed by autolytic means,the wound is irrigated.
3) Mechanical methods involve direct surgical removal of the eschar layer of the wound.
4) Enzymatic debridement may be implemented independently by the nurse whenever it is required.

Question 5

A client has a healing abdominal wound.The wound has minimal exudate and collagen formation.The wound is identified by the nurse as being in which phase of healing?
1) Primary intention
2) Inflammatory phase
3) Proliferative phase
4) Secondary intention

Question 6

The nurse is aware that application of cold is indicated for the client with:
1) Menstrual cramping
2) An infected wound
3) A fractured ankle
4) Degenerative joint disease

Question 7

The client has rheumatoid arthritis,is prone to skin breakdown,and is also somewhat immobile because of arthritic discomfort.Which of the following is the best intervention for the client's skin integrity?
1) Having the client sit up in a chair for 4-hour intervals
2) Keeping the head of the bed in a high-Fowler's position to increase circulation
3) Keeping a written schedule of turning and positioning
4) Encouraging the client to perform pelvic muscle training exercises several times a day

Question 8

Pressure ulcers form primarily as a result of:
1) Nitrogen buildup in the underlying tissues
2) Prolonged illness or disease
3) Tissue ischemia
4) Poor nutrition

Question 9

When turning a client,the nurse notices a reddened area on the coccyx.What skin care interventions should the nurse use on this area?
1) Clean the area with mild soap,dry,and add a protective moisturizer.
2) Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area.
3) Soak the area in normal saline solution.
4) Wash the area with an astringent and paint it with povidone-iodine (Betadine).

Question 10

The client has a large,deep wound on the sacral region.The nurse correctly packs the wound by:
1) Filling two thirds of the wound cavity
2) Leaving saline-soaked folded gauze squares in place
3) Putting the dressing in very tightly
4) Extending only to the upper edge of the wound

Question 11

The nurse notes a client's skin is reddened with a small abrasion and serous fluid present.The nurse should classify this stage of ulcer formation as:
1) Stage I
2) Stage II
3) Stage III
4) Stage IV

Question 12

The nurse is concerned that the client's midsternal wound is at risk for dehiscence.Which of the following is the best intervention to prevent this complication?
1) Administering antibiotics to prevent infection
2) Using appropriate sterile technique when changing the dressing
3) Keeping sterile towels and extra dressing supplies near the client's bed
4) Placing a pillow over the incision site when the client is deep breathing or coughing

Question 13

A client with a large abdominal wound requires a dressing change every 4 hours.The client will be discharged to the home setting,where the dressing care will be continued.Which of the following is true concerning this client's wound healing process?
1) An antiseptic agent is best followed with a rinse of sterile saline solution.
2) A heat lamp should be used every 2 hours to rid the wound area of contaminants.
3) Sterile technique should be emphasized to the client and family.
4) A dressing covering will allow the wound area to remain moist.

Question 14

The nurse recognizes that skin integrity can be compromised by being exposed to body fluids.The greatest risk exists for the client who has exposure to:
1) Urine
2) Purulent exudates
3) Pancreatic fluids
4) Serosanguineous drainage

Question 15

When cleaning a wound,the nurse should:
1) Wash over the wound twice and discard that swab
2) Move from the outer region of the wound toward the center
3) Start at the drainage site and move outward with circular motions
4) Use an antiseptic solution followed by a normal saline rinse

Question 16

The nurse prepares to irrigate the client's wound.The primary reason for this procedure is to:
1) Decrease scar formation
2) Remove debris from the wound
3) Improve circulation from the wound
4) Decrease irritation from wound drainage

Question 17

A client comes to the emergency department following an injury.The nurse implements appropriate first aid for the client when:
1) Removing any penetrating objects
2) Elevating an affected part that is bleeding
3) Vigorously cleaning areas of abrasion or laceration
4) Keeping any puncture wounds from bleeding

Question 18

Which nursing entry is most complete in describing a client's wound?
1) Wound appears to be healing well.Dressing dry and intact.
2) Wound well approximated with minimal drainage.
3) Drainage size of quarter;wound pink,4 × 4s applied.
4) Incisional edges approximated without redness or drainage;two 4 × 4s applied.

Question 19

The client 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:
1) At a 45-degree angle to the skin surface while pulling away from the wound
2) At a right angle to the skin surface while pulling toward the wound
3) At a right angle to the skin surface while pulling away from the wound
4) Parallel to the skin surface while pulling toward the wound

Question 20

The nurse determines that the client's wound may be infected.To perform an aerobic wound culture,the nurse should:
1) Collect the superficial drainage
2) Collect the culture before cleansing the wound
3) Obtain a culturette tube and use sterile technique
4) Use the same technique as for collecting an anaerobic culture

Question 21

The client is brought into the emergency department with a knife wound.The nurse correctly documents the client's wound as a(n):
1) Contusion wound
2) Clean wound
3) Acute wound
4) Intentional wound

Question 22

In reviewing the client's nutritional intake,the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity.The nurse suggests that the client eat:
1) Fish
2) Eggs
3) Liver
4) Citrus fruits

Question 23

The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is:
1) A reduced skin elasticity is common in the older adult
2) The attachment between the epidermis and dermis is weaker
3) The older client has less subcutaneous padding on the elbows
4) Older adults have a poor diet that increases risk for pressure ulcers

Question 24

To reduce pressure points that may lead to pressure ulcers,the nurse should:
1) Position the client directly on the trochanter when side-lying
2) Use a donut device for the client when sitting up
3) Elevate the head of the bed as little as possible
4) Massage over the bony prominences

Question 25

Although all of the following represent poor transfer techniques,which is most likely to result in a shearing injury to the skin of an older adult client?
1) Only one staff member positioning an immobile client
2) Allowing the heels to be dragged as the client is being positioned
3) Failing to lower the head of the bed before moving the client upward
4) Neglecting to use a lift sheet when moving the client to the head of the bed

Question 26

Which of the following statements made by the nurse shows the greatest insight into the need to manage the risk factors that contribute to the formation of a pressure ulcer?
1) "Her diet needs to include more protein and less sugary foods."
2) "She needs to be moved more gently and with attention to her skin."
3) "We need to decrease the time she spends with the weight of her body resting on her hip
4) "The urinary incontinency makes the risk for developing a pressure ulcer so much greater for her."

Question 27

The client has a stage IV pressure ulcer.In accordance with the Agency for Healthcare Research and Quality (AHRQ),the nurse recommends that the client should have a(n):
1) Foam mattress
2) Air-fluidized bed
3) Rotokinetic bed
4) Static support surface

Question 28

When changing the soiled linen on the bed of a client who is comatose,the nurse notices a reddened,blanchable area approximately 2 cm in diameter on her left buttock.The nurse's initial skin breakdown intervention is to:
1) Position the client on her right side
2) Finish providing fresh,dry linen to the client's bed
3) Include a 2-hour turning schedule in the client's care plan
4) Measure the area in order to describe it in the nurses' notes

Question 29

Which of the following assessment findings is most representative of a stage II pressure ulcer?
1) A blister
2) Undermining
3) Nonblanchable redness
4) Visible subcutaneous fat

Question 30

A cognitively impaired client spends hours a day involuntarily wringing her hands.Which of the following interventions is the most therapeutic as a means of minimizing this client's risk for friction damage to her hands?
1) Placing thin cotton mitts on her hands
2) Frequently distracting her with conversation
3) Regularly reminding her to stop wringing her hands
4) Getting a prescription to minimize the compulsive behavior

Question 31

The client is experiencing low back pain and is to have an aquathermia pad applied.The nurse recognizes that safe application of heat to a client's injury includes:
1) Providing a timer for the client
2) Allowing the client to adjust the temperature for comfort
3) Placing the pad directly onto the area requiring treatment
4) Using the highest temperature that is tolerated by the client

Question 32

The nurse is planning a program on wound healing and includes information that smoking influences healing by:
1) Suppressing protein synthesis
2) Creating increased tissue fragility
3) Depressing bone marrow function
4) Reducing functional hemoglobin in the blood

Question 33

A client on the medical unit is taking steroids and also has a wound from a minor injury.To promote wound healing for this client,the nurse recommends that which of the following be specifically added?
1) Iron
2) Folic acid
3) Vitamin A
4) B complex vitamins

Question 34

The client requires support,and an abdominal binder is ordered.The nurse correctly implements the use of a binder by:
1) Using it as a replacement for underlying dressings
2) Keeping it loose for client comfort
3) Having the client sit or stand when it is applied
4) Making sure the client has adequate ventilatory capacity

Question 35

Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client?
1) "2-cm area of scaly,dry skin located on the client's right heel."
2) "2-cm area of nonblanching erythema located on the client's right heel."
3) "2-cm area purplish blue in color surrounded by lighter-colored skin located on right heel."
4) "2-cm area of blanching erythema located on the client's right heel;entire foot warm to the touch."

Question 36

The nurse uses the Norton scale in the extended care facility to determine the client's risk for pressure ulcer development.Which one of the following scores,based on this scale,places the client at the highest level of risk?
1) 6
2) 8
3) 15
4) 19

Question 37

Which of the following interventions is mostly likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose?
1) Turn and position the client at least every 2 hours.
2) Use a lift sheet when moving the client up in the bed.
3) Change wet,soiled clothing as promptly as it is detected.
4) Keep the head of the client's bed elevated to less than 30 degrees.

Question 38

Which of the following statements made by the nurse shows the most thorough understanding of the therapeutic value of testing a reddened area on the heel of a mobility-impaired client for blanching?
1) "If it blanches,the problem isn't too bad."
2) "When it stays red,the damage is great."
3) "Nonblanching hyperemia is a poor indictor of healing."
4) "Blanching denotes an attempt to deliver blood to the site."

Question 39

Which of the following clients has the greatest risk for friction-induced skin breakdown?
1) A client who is obese and is frequently incontinent of both urine and feces
2) A client who insists she is comfortable only when positioned on her left side
3) A client who is cognitively impaired and comforts herself by wringing her hands
4) An immobile client who slides down in the recliner where he spends the morning hours

Question 40

When asked what the role of the skin is in maintaining homeostasis,the answer that reflects the greatest insight is:
1) "Our body needs vitamin D,and without healthy skin we cannot utilize it into a form we can use."
2) "Without skin we would not be able to enjoy the sense of touch that is so important to us as humans."
3) "The skin is a barrier that is really quite good at keeping disease-causing pathogens from getting into our body."
4) "It is the pain with its pain receptors that alert us to danger so that we can take appropriate action in order to be safe."

Question 41

The nursing student is bathing a 73-year-old Native American female client.The student reports to the nurse that the client has what looks like cyanosis on her sacrum.The nurse goes with the student to assess the client but suspects that the cyanosis that the student sees is most likely:
1) Caused from the client laying on her back most of the morning
2) Caused by the bright sunlight in the room
3) Normal hyperpigmentation of mongolian spots
4) Blue dye that has bled off the cheap new gowns that the hospital has purchased

Question 42

Granulated tissue is best described as:
1) Soft,yellow,and stringy
2) Black,hard,and necrotic
3) Red,moist,and vascular-rich
4) Yellow,spongy,and sinewy

Question 43

The nurse is assessing the pressure ulcer of a 68-year-old female client.Which of the following would indicate to the nurse that healing is taking place?
1) Eschar
2) Slough
3) Granulation tissue
4) Exudate

Question 44

Which of the following statements shows the greatest understanding of wound staging?
1) "An ulcer must involve broken skin in order to be staged."
2) "A wound that contains slough is difficult to stage."
3) "This wound can't be staged until it's debrided."
4) "The health care provider will need to stage the ulcer."

Question 45

Wounds that are contaminated or infected heal by:
1) Secondary intention
2) Tertiary intention
3) Primary intention
4) Open intention

Question 46

A client presents with a pressure ulcer that the nurse is documenting in the medical record.The nurse notes necrotic tissue on the pressure ulcer,which indicates that:
1) The pressure ulcer is automatically a stage IV
2) The pressure ulcer cannot be staged
3) The client has been abused
4) The pressure ulcer is healing

Question 47

Wounds that heal by primary intention will most likely:
1) Have minimal scarring
2) Contain infected tissue
3) Present with ragged edges
4) Have portions of missing tissue

Question 48

The inflammatory stage of healing is characterized by:
1) Throbbing pain
2) Granulation tissue
3) Wound contraction
4) Collagen scarring

Question 49

The nurse is assessing a 78-year-old female African-American client with dark skin.When assessing the skin,the nurse knows to avoid which source of light because it can cast a bluish hue on the skin,making the assessment difficult?
1) Natural sunlight
2) Halogen light
3) Florescent light
4) Incandescent light

Question 50

The nurse notes that the 43-year-old male client has an abrasion on his upper right thigh that he received 2 days ago when he was involved in a bicycle accident.The abrasion is red,swollen,warm,and throbbing.The nurse knows that the wound shows signs of being:
1) Infected
2) In the inflammatory phase of healing
3) In the proliferative phase of healing
4) In the remodeling phase of healing

Question 51

The 23-year-old female client is concerned about scarring from her hernia surgery.She had a third-degree burn on her right arm when she was younger that left a scar that she is self-conscious about.Then nurse explains to the client that the wound from the burn healed differently than the surgical incision will heal.The incision that she will have will heal by:
1) Primary intention
2) Secondary intention
3) Tertiary intention
4) Dehiscence

Question 52

The initial nursing intervention for the assessment of external hemorrhaging is:
1) Close monitoring of the wound dressing for bloody drainage
2) Frequent assessment of the client's blood pressure
3) Monitoring of the client's heart rate
4) Redressing of the wound

Question 53

Which of the following clients is most at risk for developing a pressure ulcer?
1) 3-year-old in Buck's traction
2) 33-year-old comatose client
3) 76-year-old client who has had a mild stroke
4) 38-week-old infant in an oxygen hood