Deck 35: Skin Integrity-Wound Healing

Question 1

A patient underwent abdominal surgery for a ruptured appendix.The surgeon did not surgically close the wound.The wound healing process described in this situation is:

A) Primary intention healing
B) Secondary intention healing
C) Tertiary intention healing
D) Approximation healing

Answer 1

Secondary intention healing

Question 2

Which of the following describes the difference between dehiscence and evisceration?

A) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.
B) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent.
C) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue.
D) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

Answer 2

With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

Question 3

Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives:

A) Can cause cellular toxicity
B) Increase the risk of ischemia
C) Delay wound healing
D) Predispose to hematoma formation

Answer 3

Increase the risk of ischemia

Question 4

What intervention would be most appropriate for a wound with a beefy red wound bed?

A) Mechanical debridement
B) Autolytic debridement
C) Dressing to keep the wound moist and clean
D) Removal of devitalized tissue and a sterile dressing

Question 5

Why is the information obtained from a swab culture of a wound limited?

A) A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria.
B) A negative culture may not indicate infection because chronic wounds are often colonized with bacteria.
C) Most wound infections are viral, so the swab culture would not be indicative of a wound infection.
D) A swab culture result does not include bacterial sensitivity information necessary to provide treatment.

Question 6

Pressure ulcers are directly caused by which of the following conditions at the site?

A) Compromised blood flow
B) Edema
C) Shearing forces
D) Inadequate venous return

Question 7

A man was involved in a motor vehicle accident yesterday.He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator.Which of the following would be an appropriate nursing diagnosis for him at this time?

A) Risk for Infection related to subcutaneous injuries
B) Risk for Impaired Skin Integrity related to immobility
C) Impaired Tissue Integrity related to ventilator dependency
D) Impaired Skin Integrity related to ventilator dependency

Question 8

For the client with a stage IV pressure ulcer,what would an applicable patient goal/outcome be?

A) Client will maintain intact skin throughout hospitalization.
B) Client will limit pressure to wound site throughout treatment course.
C) Wound will close with no evidence of infection within 6 weeks.
D) Wound will improve prior to discharge as evidenced by a decrease in drainage.

Question 9

When teaching a patient about the healing process of an open wound after surgery,which of the following points would the nurse make?

A) The patient will need to take antibiotics until the wound is completely healed.
B) Because the patient's wound was left open, the wound will likely become infected.
C) The patient will have more scar tissue formation than there would be for a wound closed at surgery.
D) The patient should expect to remain hospitalized until complete wound healing occurs.

Question 10

A patient had a CVA (stroke)2 days ago,resulting in decreased mobility to her left side.During the assessment,the nurse discovers a stage I pressure area on the patient's left heel.What is the initial treatment for this pressure ulcer?

A) Antibiotic treatment for 2 weeks
B) Normal saline irrigation of the ulcer daily
C) Debridement to the left heel
D) Elevation of the left heel off the bed

Question 11

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance.He also has a draining wound.Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?

A) Draw a circle around the area of drainage on a dressing.
B) Classify drainage as less or more than the previous drainage.
C) Weigh the patient at the same time each day on the same scale.
D) Weigh dressings before they are applied and after they are removed.

Question 12

What is the function of the stratum corneum?

A) Provides insulation for temperature regulation
B) Provides strength and elasticity to the skin
C) Protects the body against the entry of pathogens
D) Continually produces new skin cells

Question 13

What is the primary goal that the nurse should establish for a patient with an open wound?

A) The wound will remain free of infection throughout the healing process.
B) The client will complete antibiotic treatment as ordered.
C) The wound will remain free of scar tissue at healing.
D) The client will increase caloric intake throughout the healing process.

Question 14

A patient has a stage II pressure ulcer on her right buttock.The ulcer is covered with dry,yellow slough that tightly adheres to the wound.What is the best treatment the nurse could recommend for treating this wound?

A) Dry gauze dressing changed twice daily
B) Nonadherent dressing with daily wound care
C) Hydrocolloid dressing changed as needed
D) Wet-to-dry dressings changed three times a day

Question 15

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago,and now the ulcer appears to be a shallow crater involving only partial skin loss.What would the nurse now classify the pressure ulcer as?

A) Stage I pressure ulcer, healing
B) Stage II pressure ulcer, healing
C) Stage III pressure ulcer, healing
D) Stage IV pressure ulcer, healing

Question 16

A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis.When documenting the depth of the wound,how would the nurse classify it?

A) Partial-thickness wound
B) Penetrating wound
C) Superficial wound
D) Full-thickness wound

Question 17

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client

A) Begins an aggressive exercise program
B) Follows a diet plan of 1,200 calories per day
C) Is fitted for deep-depth diabetic footwear
D) Remains free of foot wounds

Question 18

What is the primary difference between acute and chronic wounds? Chronic wounds:

A) Are full-thickness wounds, but acute wounds are superficial
B) Result from pressure, but acute wounds result from surgery
C) Are usually infected, whereas acute wounds are contaminated
D) Exceed the typical healing time, but acute wounds heal readily

Question 19

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy.She has a pressure area on her coccyx measuring 5 cm by 3 cm.The area is covered with 100% eschar.What would the nurse identify this as?

A) Stage II pressure ulcer
B) Stage III pressure ulcer
C) Stage IV pressure ulcer
D) Unstageable pressure ulcer

Question 20

While assessing a new wound,the nurse notes red,watery drainage.How should the nurse describe this type of drainage when documenting?

A) Sanguineous
B) Serosanguineous
C) Serous
D) Purosanguineous

Question 21

Which client does the nurse recognize as being at greatest risk for pressure ulcers?

A) Infant with skin excoriations in the diaper region
B) Young adult with diabetes in skeletal traction
C) Middle-aged adult with quadriplegia
D) Older adult requiring use of assistive device for ambulation

Question 22

Your patient has a deep wound on the right hip,with tunneling at the 8 o'clock position extending 5 cm.The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed.Of the following,which would be an appropriate dressing choice?

A) Alginate dressing
B) Dry gauze dressing
C) Hydrogel
D) Hydrocolloid dressing

Question 23

The patient has shiny ulcerations on a red base over the medial calf of the right leg.There is quite a bit of fluid drainage.He takes anticoagulants because of recurrent deep vein thrombosis.He also reports a sedentary lifestyle.How would the nurse classify this chronic wound?

A) Pressure ulcer
B) Venous stasis ulcer
C) Diabetic foot ulcer
D) Arterial ulcer

Question 24

A patient had abdominal surgery.The incision has been closed by primary intention,and the staples are intact.To provide more support to the incision site and decrease the risk of dehiscence,it would be appropriate to apply which of the following?

A) Steri-Strips
B) Abdominal binder
C) T-binder
D) Paper tape

Question 25

The nurse would know care for a stage II pressure ulcer is achieving the desired goal when:

A) The ulcer is completely healed with minimal scarring
B) The patient reports no pain at the site
C) A minimal amount of drainage is noted
D) The wound bed contains 100% granulated tissue

Question 26

The nurse admits an older adult patient to the long-term care facility.When assessing for pressure ulcer risk,what should the nurse do after conducting the first Braden scale assessment?

A) Apply transparent film dressings to buttocks.
B) Reassess using the Braden Q scale.
C) Conduct another assessment in 3 days.
D) Massage areas over the bony prominences.

Question 27

While applying a wet-to-dry dressing,how would the nurse explain to the patient how this procedure works for promoting healing? A wet-to-dry dressing is a:

A) Method of submerging the wound in water, allowing it to soak before drying the wound bed
B) Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed
C) Means of debriding the wound but also removing granulation tissue from the wound
D) Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue

Question 28

What is a common characteristic of aging skin?

A) Increased permeability to moisture
B) Diminished sweat gland activity
C) Reduced oxygen-free radicals
D) Overproduction of elastin

Question 29

The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity?

A) Young adult in traction who has a low-protein diet and dehydration
B) Elderly patient diagnosed with well-controlled type 2 diabetes
C) Middle-aged adult with metabolic syndrome taking antihypertensives
D) Adolescent in bed with influenza having periods of high fever and diaphoresis

Question 30

An adult patient is fully able to detect and respond to pain and discomfort.He has no incontinence or mobility limitations.He is of normal weight and consumes a nutritious diet.The patient has no problem with rubbing,friction,or shear.What is the Braden score for this patient?

A) 0
B) 15
C) 20
D) 23

Question 31

The patient with a colostomy has been incorrectly applying his ostomy appliance.The continuous contact with liquid stool has caused a skin wound around the ostomy.The nurse assesses bleeding and purulent drainage that has extended into the dermis.How will the nurse classify and document this contaminated wound?

A) Acute, full-thickness, open
B) Chronic, partial-thickness, closed
C) Acute, partial-thickness, closed
D) Chronic, unstageable, open

Question 32

A patient has an area of nonblanchable erythema on his coccyx.The nurse has determined this to be a stage I pressure ulcer.What would be the most important treatment for this patient?

A) Transparent film dressing
B) Sheet hydrogel
C) Frequent turn schedule
D) Enzymatic debridement

Question 33

The nurse in the emergency department admits a patient with a gunshot wound to the lower abdomen accompanied by heavy bleeding.What type of drainage does the nurse expect to see on the dressing?

A) Serous
B) Sanguineous
C) Purosanguineous
D) Purulent

Question 34

Your patient has multiple open wounds that require treatment.When performing dressing changes,you should:

A) Remove all of the soiled dressings before beginning wound treatment
B) Cleanse wounds from most contaminated to least contaminated
C) Treat wounds on the patient's side first, then the front and back of the patient
D) Irrigate wounds from least contaminated to most contaminated

Question 35

The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit.Which one is it most likely to be?

A) Is actively bleeding
B) Has swollen, tender insect bite
C) Has just sprained her ankle
D) Has lower back pain

Question 36

When applying heat or cold therapy to a wound,what should the nurse do?

A) Leave the therapy on each area no longer than 15 minutes.
B) Leave the therapy on each area no longer than 30 minutes.
C) When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it.
D) When using cold, ensure the temperature is less than 32°F (0°C) before applying it.

Question 37

The patient experiences extensive third-degree burns.What type of healing does the nurse expect? Healing by:

A) Primary intention
B) Second intention
C) Tertiary intention
D) Primary intention if no infection occurs

Question 38

The nurse is caring for a patient with an infected full-thickness wound with moderate drainage and no odor.What type of dressing will be most appropriate for the nurse to apply?

A) Alginate
B) Antimicrobial petroleum gauze
C) Foam dressing
D) Antimicrobial collagen dressings

Question 39

A patient has a contaminated right hip wound that requires dressing changes twice daily.The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed.The nurse recognizes that the surgeon is using which form of wound healing?

A) Primary intention
B) Regenerative healing
C) Secondary intention
D) Tertiary intention

Question 40

Of the following,which is the best choice for performing wound irrigation?

A) Water jet irrigation
B) 35-mL syringe with a 19-gauge angiocatheter
C) 5-mL syringe with a 23-gauge needle
D) Bulb syringe

Question 41

Why is an accurate description of the location of a wound important? Select all that apply.

A) Influences the rate of healing
B) Determines the appropriate treatment choice
C) Will affect the frequency of dressing changes
D) Affects patient movement and mobility

Question 42

The nurse would question a prescription for application of cold therapy to which patient? The patient with a:

A) Wound oozing blood
B) Sprained wrist
C) Infected wound
D) Pressure ulcer

Question 43

The nurse learns in report that the assigned patient has a stage III pressure ulcer.What type of tissue does the nurse expect to find in the wound? Select all that apply.

A) Muscle
B) Eschar
C) Subcutaneous
D) Dermis
E) Fascia

Question 44

Select the process(es)that occur(s)during the inflammatory phase of wound healing.Select all that apply.

A) Granulation
B) Hemostasis
C) Epithelialization
D) Inflammation

Question 45

What are two risk assessment tools used in the United States to evaluate a patient's risk for pressure ulcers? Select all that apply.

A) Pressure Ulcer Healing Chart
B) PUSH tool
C) Braden scale
D) Norton scale

Question 46

Which of the following are examples of nonselective mechanical debridement methods? Select all that apply.

A) Wet-to-dry dressings
B) Sharp debridement
C) Whirlpool
D) Pulsed lavage

Question 47

The home health nurse learns that an elderly patient isn't able to get to the grocery store.She doesn't have much food in her home,and eats and drinks little.Most of her time is spent sitting in her chair watching television,often not realizing that she has bladder leakage.Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply.

A) Help her to get out of the chair every 2 hours.
B) Change her clothing frequently.
C) Bath the patient using soap and water.
D) Promote intake of green tea throughout the day.
E) Encourage her to wear incontinence products.

Question 48

Which actions would the nurse take when emptying the patient's closed-wound drainage system? Select all that apply.

A) Don sterile gloves and personal protective equipment.
B) Inspect the drainage tube site and sutures.
C) Check that tubing to drainage system is intact.
D) Test the suction apparatus at prescribed pressure.
E) Document the color, type, and amount of drainage.
F) None of the above