Question 1

The nurse is caring for a patient with a pressure ulcer on the left hip.The ulcer is black.The nurse recognizes that the next step in caring for this patient includes

Accepted Answer

Débridement is the removal of nonviable necrotic tissue.Removal of necrotic tissue is necessary to rid the ulcer 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 the wound 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 once débrided.When treating a pressure ulcer,it is important to monitor and reassess the wound at least every 8 hours.Management of drainage will help keep the wound clean.

Question 2

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers.The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage

Accepted Answer

Stage I intact pressure ulcers 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 II.A hydrocolloid,hydrogel covered with foam,calcium alginate,gauze,and growth factors can be utilized with a clean stage III.Hydrogel,calcium alginate,gauze,and growth factors can be utilized with a clean stage IV.An unstageable wound cover with eschar 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 ulcer.

Question 3

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,if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing.The next sequence of events includes gathering supplies for the dressing change,donning gloves,and avoiding the accidental removal of the drain during the procedure.

Question 4

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 defenses for preventing skin breakdown.Avoid soaps and hot water when cleansing the skin.Use gentle cleansers with nonionic surfactants.After bathing,make sure to dry the skin completely,and apply moisturizer to keep the epidermis well lubricated.Absorbent pads and garments are 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 defense for skin breakdown.

Question 5

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 part of this patient's nursing diagnosis,but the data provided do not support this nursing diagnosis.

Question 6

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

Accepted Answer

Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility,which in turn reduces pressure ulcer risks.It is good to encourage a patient to move about but even better if the patient actually sits up in the chair.Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability.Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours,and again does not influence the patient's ability to increase mobility.

Question 7

The nurse is completing a skin risk assessment utilizing the Braden scale.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 Braden scale total score?

Accepted Answer

With use of the Braden scale,the patient receives 3 for slight sensory impairment,4 for skin being rarely moist,3 for walks occasionally,3 for slightly limited mobility,4 for intake of meals,and 4 for no problem with friction and shear.The total score is 20.

Question 8

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

Clean dressings as opposed to sterile dressings are recommended for home use.This recommendation is in keeping with principles regarding nosocomial infection,and it takes into account the expense of sterile dressings and the dexterity required for application.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 9

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

Accepted Answer

The nurse continually assesses the skin for signs of ulcer development.Assessment of tissue pressure damage includes visual and tactile inspection of the skin.Observe pressure points such as bony prominences and areas next to 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 with a healing stage III pressure ulcer.The wound is clean and granulating.Which of the following orders would the nurse question?

Accepted Answer

Clean pressure ulcers 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 orders that would be appropriate.

Question 11

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 12

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.What is the best method for repositioning the patient?

Accepted Answer

When repositioning the patient,obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries.The patient should be placed in a 30-degree lateral position,not supine position.The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.

Question 13

The nurse is caring for a patient with a stage III pressure ulcer.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 does not relate 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 odor 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 14

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,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.Utilize foam,gel,or an air cushion to distribute weight.Longer than 2 hours can increase the chance of ischemia.

Question 15

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.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 count,and odorous and purulent drainage from the wound.The patient is unconscious and is unable to communicate the signs and symptoms of infection; also,this 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 16

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

Accepted Answer

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

Question 17

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity.The nurse consults a

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 18

The nurse is caring for a postpartum patient.The patient has an episiotomy after experiencing birth.The physician has ordered heat to treat this condition,and the nurse is providing this treatment.This patient is at risk for

Accepted Answer

Heat causes vasodilatation and is used to improve blood flow to an injured body part.The application of heat incorrectly when the treatment is too hot,or is applied too long or to the wrong place,can result in a burn for the patient and risk for additional trauma.The skin already has impaired integrity owing to the surgical procedure,and because of this has been at risk for infection since the surgical procedure was performed.This patient is of childbearing age and has had a child.Additional needs for nutrition are present during pregnancy and breastfeeding,but this is an established nursing diagnosis.Data are insufficient to support the nursing diagnosis of Imbalanced nutrition.

Question 19

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 a blocked drain,and you will need to 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 20

The nurse is caring for a patient with a stage IV pressure ulcer.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 IV pressure ulcer 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 current data in the question strongly support Impaired skin integrity.

Quiz 93: Skin Integrity and Wound Care