Deck 35: Skin Integrity and Wound Care

Question 1

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 purulent area on the side of the wound
D)Intact skin at the edge of the wound

Answer 1

Clean areas of granulation tissue

Question 2

A family member assisting with a client's transfer reports a small skin tear on the client's forearm that occurred during the one-person assist transfer.After assessing the wound,what would be the correct action for the client's nurse to implement?

A)Obtain a transparent dressing 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 family member to reevaluate the wound in 20 minutes

Answer 2

Cleanse the wound and apply a dressing

Question 3

The night nurse is assuming care of a cardiac client who wears antiembolic stockings.How should this nurse manage assessment of the skin on this client's legs?

A)Defer the assessment since 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

Answer 3

Remove the stockings for this assessment

Question 4

The emergency department physician has closed a laceration with tissue adhesive.The nurse provides the client with instruction regarding which type of wound healing?

A)Primary intention
B)Delayed primary intention
C)Secondary healing
D)Tertiary intention

Question 5

The nurse is gathering equipment to perform the irrigation of an abdominal wound that is being allowed to heal by secondary intention.Which of the following syringes would provide the recommended pounds per square inch (psi)for optimum irrigation?

A)10 to 20 mL with an 18 gauge needle
B)20-30 mL with a 24 gauge needle
C)30-60 mL with an 18 gauge needle
D)50 mL or larger with no needle

Question 6

A client who routinely takes steroid medications to control lung disease is being discharged home.Why would the discharge teaching plan emphasize information on practicing good infection control?

A)Use of steroids decreases oxygen supply to tissues.
B)Steroids suppress the inflammatory process.
C)Steroids decrease glucose in the blood.
D)Steroids cause blood vessel constriction.

Question 7

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 × 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 additional dressing to the wound without removing the original
D)Remove the dressing and replace it with a new sterile dressing

Question 8

An adult client is incontinent and wears incontinence briefs when using a wheelchair.An irritated rash has developed in the perianal area.What care should the nurse provide to reduce the risk of the development of skin maceration which may lead to a pressure ulcer?

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 9

Emergency medical services contacts the emergency department with the report that they are transporting a client who was the victim of a motor vehicle crash.The paramedics report that the client is stable,but has multiple contusions.How should the nurse prepare for this client?

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

Question 10

Mr.Barron,75 years old,has a 10 cm stage III pressure ulcer on his right hip.A recent culture has indicated growth of e-coli,and there is pus in the wound.Which of the following would determine that Mr.Barron is not a candidate for vacuum assisted closure (VAC)of his wound?

A)Presence of infection
B)Size of the wound
C)Location of his ulcer
D)His age

Question 11

What type of discharge would be observed in a new wound that is infected?

A)Thick,clear-coloured discharge
B)Serous exudate and white edges
C)Purosanguinous discharge
D)Serosanguinous discharge

Question 12

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

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

Question 13

The client has a documented stage III pressure ulcer on the right hip.Other than wound care,which of the following measures can be taken to promote healing?

A)Q4 hour turning schedule,back to left side only
B)Provide sheepskin for client to lay on
C)Providing adequate hydration
D)Clean dressing changes three times a day

Question 14

Mrs.Nichols has a stage/category III pressure ulcer on her coccyx.After 2 weeks of treatment,the nurse assesses Mrs.Nichols and documents that the ulcer is smaller in size,has new granulation tissue,and appears to be healing by secondary intention.She documents Mrs.Nichols's ulcer as a stage II.Which of the following explains why this is inaccurate?

A)A healing ulcer cannot be backstaged.
B)Pressure ulcers heal by primary intention.
C)Granulation tissue indicates early regenerative stage.
D)This is not an ulcer that can be staged.

Question 15

The nurse is using an elastic bandage to secure a dressing on a patient with a left leg wound.The elastic bandage should be wrapped from proximal to distal to promote good circulation.

Question 16

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

A)Cataract
B)Uncomplicated abdominal hysterectomy
C)Plantar Fasciotomy
D)Total hip replacement

Question 17

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 18

On the fourth post-operative 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 19

Which of the following are objectives of vacuum assisted closure (VAC)therapy?

A)Decrease wound size
B)Decrease microvascular blood flow
C)Prevent infection
D)Increase exudates

Question 20

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?

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

Question 21

The nurse has applied an aquathermia pad to a client's back.After 15 minutes of treatment,the client says that the pack is no longer warm and asks the nurse to increase the temperature.How should the nurse evaluate this request?

A)The client's thermal tolerance is higher than normal; increasing the temperature is necessary.
B)This client is 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 22

Which of the following descriptions are generally associated with venous disease ulcers?

A)Ulcers with a "punched out" appearance
B)Edema and white atrophic lesions
C)Cold feet that are either pale or blue in colour
D)Pale,dry wound bed

Question 23

What factors inhibit wound healing in the older adult?

A)Reduced cell elasticity
B)Reduced arterial blood flow
C)Nutritional deficiencies
D)Decreased white blood cells