Deck 29: Skin Integrity and Wound Care

Question 1

The nurse understands the rationale for drying a wound after irrigation is:

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

Answer 1

to prevent skin breakdown from moisture.

Question 2

The nurse is caring for a patient with a Penrose drain. She knows the patient will require the following care:

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.

Answer 2

The drain is not sutured in place so care is taken to not dislodge it.

Question 3

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. The patient complains of a "popping sensation" and a wetness in her dressing. The nurse immediately suspects:

A) a wound infection.
B) the stitches came loose.
C) wound dehiscence.
D) wound crepitus.

Answer 3

wound dehiscence.

Question 4

The nurse knows the following types 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 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 5

The nurse knows a stage III pressure ulcer is:

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 6

The nurse knows the following wound 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 7

The nurse knows to irrigate a deep wound with:

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

Question 8

The nurse is delegating care of a patient with a chronic nonsterile wound to a UAP. The delegation is inappropriate if:

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 9

The nurse knows the layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect is:

A) stratum germinativum.
B) epidermis.
C) subcutaneous layer.
D) stratum corneum.

Question 10

The nurse knows that mechanical debridement involves all of the following except:

A) wet to dry dressings.
B) whirlpool baths.
C) damp to dry dressing.
D) enzymatic dressing.

Question 11

The nurse knows that a hydrocolloid dressing is appropriate for the following 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 knows an appropriate goal for a patient with a stage III pressure ulcer with the nursing diagnosis Impaired physical mobility is:

A) the patient will remain free of wound infections during the hospitalization.
B) the patient will report pain management strategies and reduce pain to a tolerable level.
C) the patient will turn self in bed using over trapeze every two hours using assistance when needed.
D) the patient will consume adequate nutrition to meet nutritional requirements within 1 week.

Question 13

The nurse knows that the following factors contribute to the development of wounds and lead to delays in wound healing: (Select all that apply.)

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

Question 14

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

Question 15

The nurse is repositioning her patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the HOB should be placed at:

A) flat.
B) 90 degrees.
C) 30 degrees.
D) 45 degrees.

Question 16

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

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

Question 17

The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a nursing diagnosis of Impaired skin integrity is:

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

Question 18

The nurse is educating the patient about the use of heat/cold therapy at home. The following 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 19

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 20

The nurse is explaining to the student nurse the purpose of occlusive dressings. 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 21

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions should the nurse perform? (Select all that apply.)

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.

Question 22

The nurse is performing a focused wound assessment on a patient. The following should be included in the documentation: (Select all that apply.)

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 23

The nurse knows that cold therapy is contraindicated in the following conditions: (Select all that apply.)

A) Edema
B) Shivering
C) Bleeding
D) Circulatory issues

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? (Select all that apply.)

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

Question 25

The nurse knows that the cause of pressure ulcers includes the following factors: (Select all that apply.)

A) Intensity of the pressure
B) Duration of the pressure
C) The tissue's ability to tolerate the pressure
D) The person's age
E) None of the above