Deck 29: Skin Integrity and Wound Care

Question 1

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?

A) Cover the wound with a sterile gauze pad.
B) Cover the wound with a transparent dressing.
C) Put pressure on the wound with a sterile gauze pad.
D) Cover the wound with gauze soaked with normal saline.

Answer 1

Cover the wound with gauze soaked with normal saline.

Question 2

The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse should place the head of the bed in which position?

A) Flat
B) 90 degrees
C) 30 degrees
D) 45 degrees

Answer 2

30 degrees

Question 3

The nurse identifies which syringe to use when irrigating a patient's deep wound?

A) 5-mL syringe
B) 10-mL syringe
C) 3-mL syringe
D) 30-mL syringe

Answer 3

30-mL syringe

Question 4

The nurse understands which rationale to be appropriate for drying a wound after irrigation?

A) Ensure the new dressing adheres to the wound.
B) Ensure the new dressing remains occlusive.
C) Prevent skin breakdown from moisture.
D) Prevent infection from irrigate solution.

Question 5

A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?

A) The nurse asks the UAP to assess the wound.
B) The nurse asks the UAP to report increased wound drainage.
C) The nurse asks the UAP to observe changes in dietary intake.
D) The nurse asks the UAP to change the dressing.

Question 6

The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding?

A) "Occlusive dressings are used for autolytic debridement."
B) "Hydrocolloids are a type of occlusive dressing."
C) "Occlusive dressings can be used on infected wounds."
D) "Occlusive dressings support the most comfortable form of debridement."

Question 7

When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?

A) The drain must be compressed after emptying to work properly.
B) The drain must be connected to suction if ordered.
C) The drain is not sutured in place so care is taken to not dislodge it.
D) The suction pulls drainage away from the wound as it re-expands.

Question 8

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a "popping sensation" and a wetness in the dressing, the nurse immediately suspects which complication?

A) A wound infection
B) The stitches came loose
C) Wound dehiscence
D) Wound crepitus

Question 9

The nurse recognizes which intervention is not a form of mechanical debridement?

A) Wet to dry dressings
B) Whirlpool baths
C) Wet to damp dressing
D) Enzymatic dressing

Question 10

The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing?

A) A patient who has diabetes.
B) A patient with COPD.
C) A patient with on bed rest who is repositioned.
D) A patient who is obese and sweats excessively.
E) A patient on long-term steroid therapy.
F) None of above

Question 11

The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?

A) A wound with a large amount of drainage
B) A wound that is tunneling
C) A postsurgical incision with staples
D) A wound with a moderate amount of drainage

Question 12

The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?

A) Stratum germinativum
B) Epidermis
C) Subcutaneous layer
D) Stratum corneum

Question 13

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first?

A) Notify the provider.
B) Notify the wound care nurse.
C) Stop the procedure.
D) Give the patient pain medication.

Question 14

The nurse knows which description would be classified as a closed wound?

A) A large bruise on the side of the face
B) A surgical incision that is sutured closed
C) A puncture wound that is healing
D) An abrasion on the leg

Question 15

The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?

A) Wound will be completely healed in 72 hours.
B) Wound will show signs of healing within 2 weeks.
C) Patient will develop no new pressure ulcers.
D) Patient will ambulate twice a day.

Question 16

When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?

A) A pressure ulcer that involves exposure of bone and connective tissue.
B) A pressure ulcer that does not extend through the fascia.
C) A pressure ulcer that does not include tunneling.
D) A partial-thick wound that involves the epidermis.

Question 17

The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility?

A) Patient will remain free of wound infections during the hospitalization.
B) Patient will report pain management strategies and reduce pain to a tolerable level.
C) Patient will be able to assist with position changes using over bed trapeze within 1 week.
D) Patient will consume adequate nutrition to meet nutritional requirements within 1 week.

Question 18

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?

A) "The wound will be red."
B) "The wound will have pus."
C) "The wound will be warm."
D) "The wound will need to be treated."

Question 19

The nurse identifies which type of wounds heal by tertiary intention?

A) An acute wound in which the patient has sutures placed when it happened.
B) A pressure ulcer that was treated with dressing changes and is healed.
C) An acute wound in which surgical glue was used to close the wound.
D) A wound that was left open initially and closed later with sutures.

Question 20

The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for further education?

A) "I should fill my ice bag 2/3 full of ice."
B) "I should use distilled water in my Aqua-K pad."
C) "I can warm up my hot pack in the microwave."
D) "I should check the order for how long to leave the compress on."

Question 21

When the nurse is performing a focused wound assessment on a patient, what information should be included in the documentation?

A) Location and size
B) Characteristics of the wound bed
C) Patient's response to wound treatment
D) Patient's pain level
E) Presence of drainage

Question 22

The nurse recognizes that the cause of pressure ulcers includes which factors?

A) Intensity of the pressure
B) Duration of the pressure
C) Tissue's ability to tolerate the pressure
D) Person's age
E) Person's nutritional status
F) None of above

Question 23

The nurse recognizes that cold therapy is contraindicated in which conditions?

A) Edema
B) Shivering
C) Bleeding
D) Circulatory problems
E) Advanced age

Question 24

The nurse is using the Braden scale to assess the patient's risk for a pressure ulcer. Which risk categories are associated with the Braden scale?

A) Activity
B) Friction and shear
C) Moisture
D) Sensory perception
E) Cognition

Question 25

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions will the nurse perform?

A) Measure the amount of drainage in the device prior to emptying.
B) Label each drain and record them separately.
C) Recompress the device after emptying.
D) Secure the device to the patient's gown above the level of the wound.
E) Check for kinks in the tubing.