Question 1

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure injuries.The nurse has become competent in the care of pressure wounds and recognizes that which of the following is a staged pressure injury that does not require a dressing?

Accepted Answer

Stage 1 intact pressure injuries that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing.This allows visual inspection and monitoring.A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture.A composite film,hydrocolloid,or hydrogel can be utilized on a clean stage 2 pressure injury.A hydrocolloid,hydrogel covered with foam,calcium alginate,gauze,and growth factors can be utilized with a clean stage 3 injury.Hydrogel,calcium alginate,gauze,and growth factors can be utilized with a clean stage 4 injury.For an unstageable wound covered with eschar,the nurse should utilize a dressing of adherent film or gauze with an ordered solution of enzymes.In rare cases when eschar is dry and intact,no dressing is used,but this is an unstaged pressure injury.

Question 2

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?

Accepted Answer

When patients are able to sit up in a chair,the nurse should make sure to limit the amount of time to 2 hours or less.The chair sitting time should be individualized.In the sitting position,pressure on the ischial tuberosities is greater than in a supine position.Foam,gel,or an air cushion may be used to distribute weight.Sitting longer than 2 hours can increase the chance of ischemia.

Question 3

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.What would be the nurse's next best step?

Accepted Answer

Because a drainage system needs to be patent,look for drainage flow through the tubing,as well as around the tubing.A sudden decrease in drainage through the tubing may indicate drain blockage,and the nurse must notify the physician.The health care provider determines the need for drain removal and removes drains.Notifying the charge nurse,although important for communication,is not the next step in providing care for this patient.The evacuator may be compressed when a blockage is present.

Question 4

The nurse is caring for a patient with a healing stage 3 pressure injury.The wound is clean and granulating.Which of the following orders would the nurse question?

Accepted Answer

Pressure injuries should be cleaned with noncytotoxic cleansers such as normal saline,which will not kill fibroblasts and healing tissue.Cytotoxic cleansers such as Dakin's solution,acetic acid,povidone-iodine,and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds.Consulting a dietitian for the nutritional needs of the patient,utilizing a low-air-loss therapy unit to decrease pressure,and applying hydrogel dressings to provide a moist environment for healing are all appropriate orders.

Question 5

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

Accepted Answer

Foam dressings are useful for wounds with large amounts of drainage or to assist with autolytic débridement because they can be left in place for as long as 7 days.This would be the most appropriate type of dressing for this wound.A hydrogel dressing donates moisture to the wound bed.This type of dressing hydrates the wound and absorbs some smaller amounts of exudates,but it would not be appropriate for a wound with a large amount of exudate.A hydrocolloid dressing is adhesive and occlusive.This type of dressing supports healing in clean,granulating wounds,and is most useful on shallow to moderately deep wounds.It should not be used in heavily draining wounds,full-thickness wounds,or infected wounds.Transparent film traps the wound's moisture over the wound,which provides a moist environment.It is used for small,superficial wounds;it is not appropriate for a wound with a large amount of exudate.

Question 6

The nurse is using the Braden scale to complete a skin risk assessment.The patient has some sensory impairment and 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.What would be the patient's total Braden scale score?

Accepted Answer

The Braden scale is composed of six subscales: sensory perception,moisture,activity,mobility,nutrition,and friction and shear.The total score ranges from 6 to 23,and a lower total score indicates a higher risk for pressure injury development.On the Braden scale,the patient receives 3 for slight sensory impairment,4 for skin's rarely being moist,3 for walking occasionally,3 for slightly limited mobility,4 for excellent intake of meals,and 4 for no problem with friction and shear.The total score is 21.

Question 7

The nurse is caring for a patient with a wound.The patient appears anxious as the nurse is preparing to change the dressing.What should the nurse do to decrease the patient's anxiety?

Accepted Answer

Explaining the procedure educates the patient regarding the dressing change and involves him in his care,thereby allowing the patient some control in decreasing anxiety.Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient's anxiety.If the family is a support system,asking support systems to leave the room can actually increase a patient's anxiety.

Question 8

The patient in medical-surgical acute care has received a nursing diagnosis of Impaired skin integrity.Which health care provider does the nurse consult?

Accepted Answer

Assessment and a plan for the patient to optimize the diet are essential.Adequate calories,protein,vitamins,and minerals promote wound healing.The nurse is the coordinator of care,and collaborating with the dietitian would result in planning the best meals for the patient.The respiratory therapist can be consulted when a patient has issues with the respiratory system.Case management can be consulted when the patient has a discharge need.A chaplain can be consulted when the patient has a spiritual need.

Question 9

The nurse is completing an assessment of the skin's integrity,which includes which of the following?

Accepted Answer

The nurse continually assesses the skin for signs of pressure injury development.Assessment of tissue pressure damage includes visual and tactile inspection of the skin.The nurse should observe pressure points such as bony prominences and areas next to invasive treatments such as a binasal cannula and the nares.Assessment of pulses,breath sounds,and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity;however,this assessment is not a specific part of a skin assessment.

Question 10

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 of these actions should the nurse take first?

Accepted Answer

Because removal of dressings is painful,it often helps to give the patient an analgesic at least 30 minutes before the wound is exposed and the dressing is changed.The sequence of the next events includes gathering supplies for the dressing change,donning gloves,and avoiding the accidental removal of the drain during the procedure.

Question 11

The nurse is caring for a patient with a stage 3 pressure injury.The nurse has assigned a nursing diagnosis of Risk for infection.Which intervention would be most important for this patient?

Accepted Answer

The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands.Encouraging fluid and food intake helps with overall wellness and wound healing,especially protein,but an increase in carbohydrates and fats is not related to the risk of infection.If the patient will be discharged before the wound is healed,the family will certainly need education on how to care for the patient.Teaching the family how to manage the odour associated with a wound is certainly important,but these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process.

Question 12

The nurse is caring for a patient with a stage 2 pressure injury 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.What is the best goal for this patient?

Accepted Answer

Because the patient has an open wound and the skin is no longer intact to protect the tissue,the patient is at increased risk for infection.The nurse will be assessing the patient for signs and symptoms of infection,including an increase in temperature,an increase in white blood cell count,and malodorous and purulent drainage from the wound.The patient is unconscious and is unable to communicate the signs and symptoms of infection;also,enabling the patient to communicate is an intervention,not a goal,for this diagnosis.It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands,but these statements are interventions,not goals or outcomes for this nursing diagnosis.

Question 13

The nurse is caring for a patient with a pressure injury on the left hip.The pressure injury is black.The nurse recognizes that the next step in caring for this patient includes which of the following?

Accepted Answer

Débridement is the removal of nonviable necrotic tissue.Removal of necrotic tissue is necessary to rid the pressure injury of a source of infection,to enable visualization of the wound bed,and to provide a clean base for healing.A wound will not move through the phases of healing if it is infected.Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean after débridement.When the nurse is treating a pressure injury,it is important to monitor and reassess the wound at least every 8 hours.Management of drainage helps keep the wound clean.

Question 14

The nurse is caring for a patient who has a stage 4 pressure injury and is awaiting plastic surgery consultation.Which of the following specialty beds would be most appropriate?

Accepted Answer

A static air mattress,or nonpowered redistribution mattress,is utilized for the patient at high risk for skin breakdown,as in this scenario.A low-air-loss therapy unit is utilized for stage 4 pressure injury and when prevention or treatment of skin breakdown is needed.If the patient has a stage 3 or stage 4 pressure injury or a postoperative myocutaneous flap,the low-air-loss therapy unit would be an appropriate selection.A standard mattress is utilized for an individual who does not have actual or potential altered or impaired skin integrity.Lateral rotation is used for treatment and prevention of pulmonary complications associated with mobility.

Question 15

The nurse has collected the following assessment data: right heel with reddened area that does not blanch.What nursing diagnosis would the nurse assign?

Accepted Answer

The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion),which has resulted in tissue damage.The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion.Risk for infection,Acute pain,and Imbalanced nutrition may be other nursing diagnoses,but the data provided do not support them.

Question 16

The nurse is cleansing a wound site.As the nurse is doing so,what intervention should be included?

Accepted Answer

The nurse cleanses surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations.Cleansing proceeds in a direction from the least contaminated area.The nurse should use gentle friction when applying solutions to the skin and allow irrigation to flow from the least to the most contaminated area.

Question 17

The nurse is caring for a patient with a stage 4 pressure injury.The nurse assigns which of the following nursing diagnoses?

Accepted Answer

After the assessment is completed and the information that the patient has a stage 4 pressure injury is gathered,a diagnosis of Impaired skin integrity is selected.Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved.Impaired physical mobility and Chronic pain,as well as the nutrition nursing diagnosis,could well be the nursing diagnoses selected for this patient,but the physical data in the question strongly support Impaired skin integrity.

Question 18

The home health nurse is caring for a patient with impaired skin integrity in the home.The nurse is reviewing dressing changes with the caregiver.Which intervention assists in managing the expenses associated with long-term wound care?

Accepted Answer

The caregiver can use the same no-touch technique for dressing changes that is used for changing surface dressings without touching the wound or the surface that might come in contact with the wound.Double bagging is required for the disposal of contaminated dressings.The dressings go in a bag,which is fastened and then placed in the household trash.The ability of the caregiver certainly is a component of the success of home treatment,but it does not influence the cost of supplies.

Question 19

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 interventions should the nurse select to decrease this risk?

Accepted Answer

Assessment and skin hygiene are two initial defences for preventing skin breakdown.The nurse should avoid soaps and hot water when cleansing the skin and should instead use gentle cleansers with nonionic surfactants.After the patient is bathed,the nurse makes sure to dry the skin completely and to apply moisturizer to keep the epidermis well lubricated.The use of absorbent pads and garments is controversial and should be considered only when other alternatives have been exhausted.Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components.Depending on the needs of the patient,a specialty bed may be needed,but again,this does not provide the initial defence against skin breakdown.

Question 20

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

Accepted Answer

The patient has a large abdominal incision.This incision will need support to remain closed,and an abdominal binder will support this wound,especially during movement,as well as during deep breathing and coughing.A binder can be used to create pressure over a body part: for example,over an artery after it has been punctured,but this is not the best explanation for using the binder in this example.A binder can be used to prevent edema-for example,in an extremity-but is not used to reduce edema at a surgical site.A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping,but this is not the best explanation for using the binder in this example.

Quiz 46: Skin Integrity and Wound Care