Deck 46: Skin Integrity and Wound Care

Question 1

The nurse is caring for a patient with a healing stage 3 pressure injury.Upon entering the room,the nurse notices an odour 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.

Answer 1

Complete the head-to-toe assessment,and include current treatment,vital signs,and laboratory results.

Question 2

The nurse is collaborating with the dietitian in treatment of a patient with a stage 3 pressure injury.After the collaboration,the nurse orders a meal plan that includes increased levels of what?

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

Answer 2

Protein.

Question 3

The nurse is admitting an older patient from a nursing home.During the assessment,the nurse notes a shallow open pressure injury without slough on the right heel of the patient.How would this pressure injury be staged?

A)Stage 1.
B)Stage 2.
C)Stage 3.
D)Stage 4.

Answer 3

Stage 2.

Question 4

The nurse is caring for a patient with a stage 4 pressure injury.The nurse recalls that a pressure injury takes time to heal and that the healing process is an example of which of the following?

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

Question 5

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,what is the next best step?

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

Question 6

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 malodorous and purulent.

Question 7

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 8

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 how long?

A)4 days.
B)2 days.
C)1 day.
D)7 days.

Question 9

The wound care nurse visits a patient in the long-term care unit.The nurse is monitoring a patient with a stage 3 pressure injury.The wound seems to be healing,and healthy tissue is observed.How would the nurse stage this pressure injury?

A)Stage 1 pressure injury.
B)Healing stage 2 pressure injury.
C)Healing stage 3 pressure injury.
D)Stage 3 pressure injury.

Question 10

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.What is the major element involved in the development of a pressure injury?

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

Question 11

Which nursing observation would indicate that the patient was at risk for pressure injury 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 12

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure injuries.The nurse recognizes that the risk factors that predispose a patient to pressure injury development include which of the following?

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

Question 13

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 a pressure injury on this patient?

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

Question 14

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

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

Question 15

The nurse is caring for a patient who is undergoing 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 nurse is caring for a patient who has undergone a laparoscopic appendectomy.The nurse recalls that this type of wound heals by which process?

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

Question 17

The nurse is completing an assessment on an individual who has a stage 4 pressure injury.The wound is malodorous,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 18

A patient has developed a pressure injury.What laboratory data would be important to gather?

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

Question 19

The nurse is caring for a patient who has undergone 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 colour.

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)Severe scarring.

Question 21

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure injuries.The nurse has become competent in the care of pressure wounds and recognizes that which of the following is a staged pressure injury that does not require a dressing?

A)Stage 1.
B)Stage 2.
C)Stage 3.
D)Stage 4.

Question 22

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 23

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 24

The nurse is caring for a patient with a healing stage 3 pressure injury.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 25

On inspection of the patient's wound,the nurse notes that it has a large amount of exudate.Which of the following is an appropriate dressing for the nurse to select?

A)Foam.
B)Hydrogel.
C)Hydrocolloid.
D)Transparent film.

Question 26

The nurse is using the Braden scale to complete a skin risk assessment.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 total Braden scale score?

A)15.
B)17.
C)21.
D)23.

Question 27

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 28

The patient in medical-surgical acute care has received a nursing diagnosis of Impaired skin integrity.Which health care provider does the nurse consult?

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

Question 29

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

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

Question 30

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 31

The nurse is caring for a patient with a stage 3 pressure injury.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 odour associated with the wound.
B)Discuss with the family how to prepare for care of the patient in the home.
C)Encourage thorough hand hygiene by all individuals caring for the patient.
D)Encourage increased quantities of carbohydrates and fats.

Question 32

The nurse is caring for a patient with a stage 2 pressure injury 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 malodorous or purulent drainage from the wound.
D)The patient's family members will wash their hands when visiting the patient.

Question 33

The nurse is caring for a patient with a pressure injury on the left hip.The pressure injury is black.The nurse recognizes that the next step in caring for this patient includes which of the following?

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

Question 34

The nurse is caring for a patient who has a stage 4 pressure injury and is 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 35

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 36

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

A)Allowing the solution to flow from the most contaminated area to the least contaminated area.
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 37

The nurse is caring for a patient with a stage 4 pressure injury.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 38

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)No-touch technique.
C)Double bagging of contaminated dressings.
D)Ability of the caregiver.

Question 39

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 40

The nurse is caring for a patient after an open repair of an abdominal aortic aneurysm.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 41

The nurse is caring for a patient with potential skin breakdown.Which components would the nurse include in the skin assessment? (Select all that apply. )

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

Question 42

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? (Select all that apply. )

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 43

The nurse is caring for a patient with a stage 2 pressure injury 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? (Select all that apply. )

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

Question 44

The nurse is caring for a patient with wound healing by tertiary intention.Which factors does the nurse recognize as influencing wound healing? (Select all that apply. )

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

Question 45

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a score of 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 46

The nurse determines that the patient's wound may be infected.In order to obtain a quantitative swab for wound culture,which of the following actions should the nurse take?

A)Collect the superficial drainage.
B)Collect the culture before cleansing the wound.
C)Obtain a Culturette tube and use sterile technique.
D)Use the same technique as for collecting an anaerobic culture.