Deck 93: Skin Integrity and Wound Care

Question 1

The nurse is caring for a patient who has experienced a laparoscopic appendectomy.The nurse recalls that this type of wound heals by

A) Tertiary intention.
B) Secondary intention.
C) Partial-thickness repair.
D) Primary intention.

Answer 1

D
A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention.The skin edges are approximated or closed,and the risk for infection is low.Partial-thickness repairs are done on partial-thickness wounds that are shallow,involving loss of the epidermis and maybe partial loss of the dermis.These wounds heal by regeneration because the epidermis regenerates.Tertiary intention is seen when a wound is left open for several days,and then the wound edges are approximated.Wound closure is delayed until the risk of infection is resolved.A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention.The wound is left open until it becomes filled with scar tissue.It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.

Question 2

The nurse is caring for a patient who has experienced a total hysterectomy.Which nursing observation would indicate that the patient was experiencing a complication of wound healing?

A) The incision site has started to itch.
B) The incision site is approximated.
C) The patient has pain at the incision site.
D) The incision has a mass, bluish in color.

Answer 2

D
A hematoma is a localized collection of blood underneath the tissues.It appears as swelling,change in color,sensation,or warmth or a mass that often takes on a bluish discoloration.A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow.Itching of an incision site can be associated with clipping of hair,dressings,or possibly the healing process.Incisions should be approximated with edges together.After surgery,when nerves in the skin and tissues have been traumatized by the surgical procedure,it is expected that the patient would experience pain.

Question 3

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers.The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include

A) A diet low in calories and fat.
B) Alteration in level of consciousness.
C) Shortness of breath.
D) Muscular pain.

Answer 3

B
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves.The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort.Impaired sensory perception,impaired mobility,shear,friction,and moisture are other predisposing factors.Shortness of breath,muscular pain,and a diet low in calories and fat are not included among the predisposing factors.

Question 4

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?

A) The patient ate two thirds of breakfast.
B) The patient has fecal incontinence.
C) The patient has a raised red rash on the right shin.
D) The patient's capillary refill is less than 2 seconds.

Question 5

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer.After the collaboration,the nurse orders a meal plan that includes increased

A) Fat.
B) Carbohydrates.
C) Protein.
D) Vitamin E.

Question 6

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago.The patient sustained a head injury and is unconscious.The nurse is able to identify that the major element involved in the development of a decubitus ulcer is

A) Pressure.
B) Resistance.
C) Stress.
D) Weight.

Question 7

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?

A) Complaint by patient that something has given way
B) Protrusion of visceral organs through a wound opening
C) Chronic drainage of fluid through the incision site
D) Drainage that is odorous and purulent

Question 8

The nurse is caring for a patient with a stage IV pressure ulcer.The nurse recalls that a pressure ulcer takes time to heal and is an example of

A) Primary intention.
B) Partial-thickness wound repair.
C) Full-thickness wound repair.
D) Tertiary intention.

Question 9

The nurse is caring for a patient in the burn unit.The nurse recalls that this type of wound heals by

A) Tertiary intention.
B) Secondary intention.
C) Partial-thickness repair.
D) Primary intention.

Question 10

The nurse is completing a skin assessment on a patient with darkly pigmented skin.Which of the following would be used first to assist in staging an ulcer on this patient?

A) Cotton-tipped applicator
B) Disposable measuring tape
C) Sterile gloves
D) Halogen light

Question 11

Which of the following would be the most important piece of assessment data to gather with regard to wound healing?

A) Muscular strength assessment
B) Sleep assessment
C) Pulse oximetry assessment
D) Sensation assessment

Question 12

A patient has developed a decubitus ulcer.What laboratory data would be important to gather?

A) Serum albumin
B) Creatine kinase
C) Vitamin E
D) Potassium

Question 13

The nurse is caring for a patient with a healing stage III pressure ulcer.Upon entering the room,the nurse notices an odor and observes a purulent discharge,along with increased redness at the wound site.What is the next best step for the nurse?

A) Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results.
B) Notify the charge nurse about the change in status and the potential for infection.
C) Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR).
D) Notify the wound care nurse about the change in status and the potential for infection.

Question 14

A patient presents to the emergency department with a laceration of the right forearm caused by a fall.After determining that the patient is stable,the next best step is to

A) Inspect the wound for bleeding.
B) Inspect the wound for foreign bodies.
C) Determine the size of the wound.
D) Determine the need for a tetanus antitoxin injection.

Question 15

The nurse is caring for a patient who is experiencing a full-thickness repair.The nurse would expect to see which of the following in this type of repair?

A) Eschar
B) Slough
C) Granulation
D) Purulent drainage

Question 16

The wound care nurse visits a patient in the long-term care unit.The nurse is monitoring a patient with a stage III pressure ulcer.The wound seems to be healing,and healthy tissue is observed.How would the nurse stage this ulcer?

A) Stage I pressure ulcer
B) Healing stage II pressure ulcer
C) Healing stage III pressure ulcer
D) Stage III pressure ulcer

Question 17

The nurse is caring for a patient with a large abrasion from a motorcycle accident.The nurse recalls that if the wound is kept moist,it can resurface in _____ day(s).

A) 4
B) 2
C) 1
D) 7

Question 18

The nurse is admitting an older patient from a nursing home.During the assessment,the nurse notes a shallow open ulcer without slough on the right heel of the patient.This pressure ulcer would be staged as stage

A) I.
B) II.
C) III.
D) IV.

Question 19

The nurse is completing an assessment on an individual who has a stage IV pressure ulcer.The wound is odorous,and a drain is currently in place.The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following?

A) "I think I will be ready to go home early next week."
B) "I am so weak and tired, I want to feel better."
C) "I am ready for my bath and linen change as soon as possible."
D) "I am hoping there will be something good for dinner tonight."

Question 20

Which nursing observation would indicate that a wound healed by secondary intention?

A) Minimal scar tissue
B) Minimal loss of tissue function
C) Permanent dark redness at site
D) Scarring can be severe.

Question 21

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

A) Monitoring of the wound.
B) Irrigation of the wound.
C) Débridement of the wound.
D) Management of drainage.

Question 22

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

A) I.
B) II.
C) III.
D) IV.

Question 23

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?

A) Don sterile gloves.
B) Provide analgesic medications as ordered.
C) Avoid accidentally removing the drain.
D) Gather supplies.

Question 24

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?

A) Gentle cleaners and thorough drying of the skin
B) Absorbent pads and garments
C) Positioning with use of pillows
D) Therapeutic beds and mattresses

Question 25

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

A) Ineffective tissue perfusion
B) Risk for infection
C) Imbalanced nutrition: less than body requirements
D) Acute pain

Question 26

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?

A) Encourage the patient to sit up in the chair.
B) Provide analgesic medication as ordered.
C) Explain the risks of immobility to the patient.
D) Turn the patient every 3 hours while in bed.

Question 27

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?

A) 15
B) 17
C) 20
D) 23

Question 28

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?

A) Sterile technique
B) Clean dressings and no touch technique
C) Double bagging of contaminated dressings
D) Ability of the caregiver

Question 29

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

A) Pressure points.
B) All pulses.
C) Breath sounds.
D) Bowel sounds.

Question 30

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?

A) Use a low-air-loss therapy unit.
B) Consult a dietitian.
C) Irrigate with hydrogen peroxide.
D) Utilize hydrogel dressing.

Question 31

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?

A) Tell the patient to close his eyes.
B) Explain the procedure.
C) Turn on the television.
D) Ask the family to leave the room.

Question 32

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?

A) Obtain assistance and use the drawsheet to place the patient into the new position.
B) Place the patient in a 30-degree supine position.
C) Utilize a transfer sliding board and assistance to slide the patient into the new position.
D) Elevate the head of the bed 45 degrees.

Question 33

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?

A) Teach the family how to manage the odor associated with the wound.
B) Discuss with the family how to prepare for care of the patient in the home.
C) Encourage thorough handwashing of all individuals caring for the patient.
D) Encourage increased quantities of carbohydrates and fats.

Question 34

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?

A) At least 3 hours
B) Not longer than 30 minutes
C) Less than 2 hours
D) As long as the patient remains comfortable

Question 35

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?

A) The patient's family will demonstrate specific care of the wound site.
B) The patient will state what to look for with regard to an infection.
C) The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound.
D) The patient's family members will wash their hands when visiting the patient.

Question 36

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?

A) Standard mattress
B) Nonpowered redistribution air mattress
C) Low-air-loss therapy unit
D) Lateral rotation

Question 37

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

A) Respiratory therapist.
B) Registered dietitian.
C) Chaplain.
D) Case manager.

Question 38

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

A) Infection.
B) Impaired skin integrity.
C) Trauma.
D) Imbalanced nutrition.

Question 39

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?

A) Remove the drain; a drain is no longer needed.
B) Call the physician; a blockage is present in the tubing.
C) Call the charge nurse to look at the drain.
D) As long as the evacuator is compressed, do nothing.

Question 40

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

A) Readiness for enhanced nutrition
B) Impaired physical mobility
C) Impaired skin integrity
D) Chronic pain

Question 41

The nurse is caring for a patient after an open abdominal aortic aneurysm repair.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?

A) The binder creates pressure over the abdomen.
B) The binder supports the abdomen.
C) The binder reduces edema at the surgical site.
D) The binder secures the dressing in place.

Question 42

The nurse is caring for a postoperative medial meniscus repair of the right knee.To assist with pain management following the procedure,which intervention should the nurse implement?

A) Monitor vital signs every 15 minutes.
B) Apply brace to right knee.
C) Elevate right knee and apply ice.
D) Check pulses in right foot.

Question 43

The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach.The nurse evaluates the need for several consults.Which of the following should always be included in the consults?

A) Registered dietitian
B) Enterostomal and wound care nurse
C) Physical therapist
D) Case management personnel
E) Chaplain
F) Pharmacist

Question 44

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

A) Allowing the solution to flow from the most contaminated to the least contaminated
B) Scrubbing vigorously when applying solutions to the skin
C) Cleansing in a direction from the least contaminated area
D) Utilizing clean gauge and clean gloves to cleanse a site

Question 45

The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder.The nurse's responsibilities and activities before applying the bandage and binder include which of the following?

A) Inspecting the skin for abrasions and edema
B) Covering exposed wounds
C) Assessing condition of current dressings
D) Assessing the skin at underlying areas for circulatory impairment
E) Marking the sites of all abrasions
F) Cleansing the area with hydrogen peroxide

Question 46

The nurse is completing a skin assessment on a medical-surgical patient.Which nursing assessment questions should be included in a skin integrity assessment?

A) "Can you easily change your position?"
B) "Do you have sensitivity to heat or cold?"
C) "How often do you need to use the toilet?"
D) "Is movement painful?"
E) "What medications do you take?"
F) "Have you ever fallen?"

Question 47

The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity.Which of the following outcomes when met indicate progression toward goals?

A) Ask whether patient's expectations are being met.
B) Prevent injury to the skin and tissues.
C) Obtain the patient's perception of interventions.
D) Reduce injury to the skin.
E) Reduce injury to the underlying tissues.
F) Restore skin integrity.

Question 48

The nurse is caring for a patient with wound healing by tertiary intention.Which factors does the nurse recognize as influencing wound healing?

A) Nutrition
B) Evisceration
C) Tissue perfusion
D) Infection
E) Hemorrhage
F) Age

Question 49

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission.The nurse has implemented interventions for this nursing diagnosis.Upon reassessment,which Braden score would be the best sign that the risk for skin breakdown is decreasing?

A) 12
B) 13
C) 20
D) 23

Question 50

The nurse is caring for a patient with potential skin breakdown.Which components would the nurse include in the skin assessment?

A) Mobility
B) Hyperemia
C) Induration
D) Blanching
E) Temperature of skin
F) Nutritional status