Deck 39: Prevention and Care of Skin Breakdown

Question 1

The nurse should consider culturing a wound when which one of the following situations occurs?

A) The tissue is clean and dry.
B) Exudate is not present.
C) The patient is afebrile.
D) The surrounding area shows inflammation.

Answer 1

The surrounding area shows inflammation.

Question 2

The nurse is caring for a patient who has a dressing over a surgical wound created the night before.The dressing has never been changed.How should the nurse proceed?

A) Change the dressing so she can assess the wound.
B) Administer an analgesic 30 to 45 minutes before a dressing change.
C) Culture the wound if wound exudate is present.
D) Administer an analgesic 30 minutes after a dressing change.

Answer 2

Administer an analgesic 30 to 45 minutes before a dressing change.

Question 3

The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx.The patient complains of pain at the site,and the site feels cooler than the areas immediately around the site.The nurse recognizes that this patient has developed

A) a stage 1 pressure injury.
B) a stage 2 pressure injury.
C) an unstageable pressure injury.
D) deep tissue injury.

Answer 3

a stage 1 pressure injury.

Question 4

A patient with anemia is at risk for developing pressure injuries as a result of which of the following?

A) Increased sedation
B) Edematous tissues
C) Reduced tensile strength
D) Diminished oxygen to the tissues

Question 5

The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours.While turning the patient,to what should the nurse who is performing the assessment pay particular attention?

A) Edema in the sacrum
B) Skin texture
C) Skin temperature
D) Pallor or mottling of the skin

Question 6

The nurse prepares to irrigate the patient's wound.What is the primary reason for this procedure?

A) Decrease scar formation.
B) Remove debris from the wound.
C) Improve circulation from the wound.
D) Decrease irritation from wound drainage.

Question 7

Healing by primary intention is expected to occur with which of the following situations?

A) The wound is left open and is allowed to heal.
B) A surgical wound is left open for 3 to 5 days.
C) Connective tissue development is evident.
D) The edges of a clean incision remain close together.

Question 8

The patient is admitted with an open pressure injury with necrotic tissue around the base of the wound.How would the nurse classify this ulcer?

A) Stage 3 pressure injury
B) Stage 4 pressure injury
C) Wound that cannot be staged
D) Stage 2 pressure injury

Question 9

A nurse classifies a pressure ulcer according to the type of tissue in the wound bed.What does it indicate if the wound bed has granulation in it?

A) Wound needs debridement
B) The presence of significant infection
C) Colonization by bacteria
D) Movement toward healing

Question 10

When evaluating a patient,the nurse observes an unexpected outcome of treatment when the surrounding skin of a pressure injury becomes macerated.The nurse should

A) obtain a wound culture.
B) apply pressure-reducing devices.
C) use dressings with increased moisture absorption.
D) monitor the patient for systemic signs and symptoms.

Question 11

The nurse is changing a surgical dressing and is cleansing the wound.She knows that

A) the incision line should be cleansed last.
B) she should start at one end of the incision line and swab the entire length.
C) she should start at the centre of the incision line and swab toward one end.
D) she should work in a circular motion around the incision line.

Question 12

In a long-term care facility,how often should the nurse reassess a patient for risk of a pressure ulcer?

A) Every 1 to 2 days
B) Every time the nurse sees the patient
C) Weekly for the first few weeks of stay
D) Monthly for the first 4 months of stay

Question 13

The patient with a nasogastric (NG)tube in place may experience skin breakdown

A) in the nose.
B) on the tongue.
C) behind the ears.
D) around the lips.

Question 14

When teaching about wound care in the home environment,the nurse instructs the patient and caregiver to

A) make normal saline with 8 teaspoons of salt and 3.5 L of distilled water.
B) use normal saline for 1 week and then discard it.
C) not apply topical anaesthetics before wound care.
D) call the physician's office to have someone come to the home and complete the wound care.

Question 15

The nurse is caring for four patients during a shift.Which of the following patients is at greatest risk for developing a pressure injury?

A) The patient who is bedridden,but who turns himself randomly
B) The patient whose Braden Scale score is 8
C) The patient who can ambulate to the bathroom independently
D) The patient whose Braden Scale score is 18

Question 16

On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?

A) Graft sites
B) Wounds with exposed blood vessels
C) Necrotic tissue
D) Wounds with exposed muscle or tendons

Question 17

Which of the following approaches is correct technique when wound irrigation is performed?

A) Placing the patient in supine position
B) Placing the syringe directly into the wound
C) Using sterile technique for a chronic wound
D) Selecting a soft catheter for deep wounds with small openings

Question 18

After teaching a home caregiver how to manage a pressure ulcer,the nurse realizes that further education is needed when the caregiver says:

A) "I will be sure to reposition her frequently and keep her off of the pressure ulcer."
B) "I will wash the pressure ulcer with saline and report any changes in the drainage."
C) "I know that a thick,black covering will protect the pressure ulcer from getting worse."
D) "I will let you know if the pressure ulcer starts to smell rotten."

Question 19

In a patient with a stage 2 pressure injury,the nurse describes the wound as

A) superficial blistering.
B) nonblanchable redness.
C) loss of skin without bone exposure.
D) loss of skin with exposed muscle.

Question 20

The nurse is in the process of irrigating the wound for a patient who has a large pressure injury on his buttock.How should the nurse proceed?

A) Use irrigation pressures of less than 4 psi.
B) Cleanse in a direction from most contaminated to least contaminated.
C) Irrigate so that the solution flows from least contaminated to most contaminated.
D) Irrigate with clean irrigation solution only.

Question 21

The Jackson-Pratt (JP)drain relies on the presence of a vacuum to withdraw drainage and is considered a(n)__________ drainage system.

A) open
B) closed
C) venting
D) suction

Question 22

The nurse is aware that pressure injuries can occur (Select all that apply.)

A) from any position that causes soft tissue compression.
B) because of lack of blood flow (ischemia).
C) only in bed bound patients.
D) in as little as 90 minutes.

Question 23

The removal of devitalized tissue in a wound is known as ______________.

A) eschar
B) sloughing
C) granulation
D) debridement

Question 24

Patients are at risk for developing pressure injuries on which areas of the body? (Select all that apply.)

A) Coccyx
B) Nares
C) Ears
D) Genitalia
E) None of the above

Question 25

Which situation noticed during evaluation would determine that the staples or sutures should remain in place?

A) The wound edges are separated.
B) No drainage or erythema is present.
C) The patient is anxious about their removal.
D) A cosmetically aesthetic result would not be achieved.

Question 26

What is an appropriate technique for the nurse to implement for drainage evacuation?

A) Replace the Hemovac drain fully expanded.
B) Attach the drainage tubing to the patient's gown.
C) Tilt the evacuator of the Hemovac away from the plug.
D) Complete the dressing change before the drainage evacuation.

Question 27

The nurse is explaining wound healing to a patient.Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound?

A) A reduction in the size of the wound is noted.
B) The epithelial cells duplicate.
C) Synthesis of collagen occurs at the site.
D) Blood flow to the wound and arrival of white blood cells are increased.

Question 28

___________ is black,brown,or tan tissue in the wound that should be removed before wound healing can begin.

A) The epidermis
B) The dermis
C) Eschar
D) Granulation

Question 29

_____________ uses the mechanical force (high or low)of a stream of solution to remove debris,bacteria,and necrotic tissue from a wound.

A) Suturing
B) Stapling
C) Irrigation
D) Debridement

Question 30

The physician expects that the patient's wound will have an output of close to 500 mL/day.The nurse anticipates placement of which of the following?

A) Dry sterile dressing
B) Jackson-Pratt (JP)drain
C) Hemovac drain
D) No drain

Question 31

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing.Which of the following can be appropriately delegated to an unregulated care provider?

A) Performing a sterile dressing change
B) Observing for any drainage on the dressing
C) Performing wound assessment during the dressing change
D) Notifying the physician of drainage present on the dressing

Question 32

When skin layers adhere to the linens and deeper tissue layer move downward,________ damage occurs.

A) adhesive
B) drying
C) shear
D) slough

Question 33

The healing ridge is composed of newly formed collagen,and the nurse can usually feel it along a healing wound.The nurse knows it is usually present directly under the suture line on days

A) 0 to 2.
B) 3 to 4.
C) 5 to 9.
D) 10 to 14.

Question 34

What should the nurse do to re-establish the vacuum of the Hemovac system after emptying?

A) Place a safety pin on the part of the drain outside the body.
B) Replace the cap immediately after emptying.
C) Pin the drainage tubing to the patient's gown.
D) Place the Hemovac on a flat surface.

Question 35

What should the nurse do when removing intermittent sutures?

A) Snip both sides of the suture before removing.
B) Snip the suture as close to the knot as possible.
C) Snip the suture as close to the skin as possible.
D) Pull up the knot to apply as much tension as possible.

Question 36

The nurse is educating a patient about his role in wound healing.Which of the following factors,if modified by the patient,can support adequate oxygenation at the tissue level?

A) Age
B) Smoking
C) Underlying cardiopulmonary conditions
D) Hemoglobin

Question 37

Healing by ________ intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

A) primary
B) secondary
C) tertiary
D) open

Question 38

A _______________ is a localized injury to the skin or underlying tissue,usually over a bony prominence,as a result of pressure,or pressure in combination with shear or friction.

A) pressure ulcer
B) pressure injury
C) contusion
D) hematoma

Question 39

What should the nurse do when performing suture or staple removal?

A) Snip both ends of the sutures.
B) Apply tension to the suture line to remove the sutures.
C) Pull the exposed surface of the suture through the tissue below the epidermis.
D) Apply Steri-Strip if any separation greater than the width of two stitches is present.

Question 40

___________ are threads of wire or other materials used to sew body tissues together.

A) Sutures
B) Staples
C) Adhesions
D) Lacerations

Question 41

The nurse is caring for a patient who has had major abdominal surgery and is concerned about the possibility of dehiscence.During the assessment,the nurse assesses for which of the following contributing factors? (Select all that apply.)

A) Age
B) Malnutrition/obesity
C) Gender
D) Use of steroids

Question 42

The nurse is explaining healing of a full-thickness wound to a patient.Which of the following phases should the nurse include in the explanation? (Select all that apply.)

A) Hemostasis
B) Inflammation
C) Proliferation
D) Maturation
E) None of the above

Question 43

The nurse knows that which of the following factors contribute to the development of pressure injuries? (Select all that apply.)

A) Friction and shear
B) Immobility
C) Poor nutrition
D) Moisture and ammonia
E) Uncontrolled pain

Question 44

The nurse is planning care for her patient who has a stage 2 pressure injury.Care should include which of the following? (Select all that apply.)

A) A heat lamp to dry the wound
B) Application of topical antibiotics
C) Nutritional assessment
D) Maintaining moisture in the wound

Question 45

Wounds that have been approved for treatment using negative-pressure wound therapy (NPWT)include which of the following? (Select all that apply.)

A) Pressure ulcers
B) Diabetic ulcers
C) Traumatic wounds
D) Venous stasis ulcers
E) None of the above

Question 46

The nurse is explaining negative-pressure wound therapy (NPWT)to a patient.Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.)

A) NPWT optimizes blood flow.
B) NPWT will remove wound fluid.
C) NPWT will maintain a moist environment.
D) NPWT will apply positive pressure to the wound.

Question 47

How does the skin defend the body? (Select all that apply.)

A) Skin serves as a sensory organ for pain.
B) Skin serves as a sensory organ for touch.
C) Skin serves as a sensory organ for temperature.
D) Skin has an acid pH.
E) None of the above