Question 1

The nurse is caring for a patient with a puncture wound.How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

A) 1 year
B) 3 years
C) 5 years
D) 10 years

Accepted Answer

Hydrogel dressings contain a high percentage of water and are indicated for wounds that have a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue).Gauze dressings are best for wounds with moderate drainage,deep wounds,undermining,and tunnels.Transparent film dressings are used as a primary dressing in wounds with minimal tissue loss that have very little wound drainage.Hydrocolloid dressings are used for stage 1,2,and 3 pressure injuries.

Question 2

How will the nurse obtain a culture of the patient's wound?&#10;A) Obtain a sample from the patient's wound drainage bag.&#10;B) Obtain a sample of the drainage around the edge of the wound.&#10;C) Obtain a sample of the drainage from the dressing on the wound.&#10;D) Gently swab the center of the wound after irrigating with sterile saline.

Accepted Answer

The nurse should gently swab the center of the wound after irrigating with sterile saline in order to obtain an accurate culture.Samples should never be taken from the edge of the wound,from the dressing,or from the wound drainage bag.

Question 3

What is the primary advantage of a hydrogel dressing for wound healing?&#10;A) Provide moisture needed for wound healing.&#10;B) Act as an absorbent to collect wound drainage.&#10;C) Provide negative pressure to promote healing.&#10;D) Provide protection from the external environment.

Accepted Answer

Hydrogels maintain moisture in some wounds for 1 to 3 days.Hydrogel dressings are available in sheets or in a gel in a tube (amorphous).They contain a high percentage of water and are indicated for wounds that require moisture,either a wound with granulation (maintaining the moist wound environment needed for healing)or a wound that has a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue).Negative-pressure wound therapy supports wound healing by evacuating wound fluids,stimulating granulation tissue formation,reducing the bacterial burden of a wound,and maintaining a moist wound environment.Gauze dressings are best for wounds with moderate drainage,deep wounds,undermining,and tunnels.You apply gauze either moist or dry.The moistened gauze increases the absorptive ability of the dressing to collect exudate.A transparent or hydrocolloid dressing protects against the external environment.

Question 4

The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.Which term will the nurse use to describe this area?&#10;A) Reactive hyperemia&#10;B) Secondary erythema&#10;C) Blanchable hyperemia&#10;D) Nonblanchable erythema

Accepted Answer

Nonblanchable erythema is redness that persists after palpation and indicates tissue damage.When you press a finger against the red or purple area,it does not turn lighter in color.Deep tissue damage is present and is commonly the first stage of pressure injury development.There is no such condition as secondary erythema.Reactive hyperemia is a redness of the skin resulting from dilation of the superficial capillaries.Reactive hyperemia blanches.In blanchable hyperemia,the area that appears red and warm will blanch (turn lighter in color)following fingertip palpation.

Question 5

The patient's wound has thick creamy yellow drainage present on the dressing.How will the nurse document this finding?&#10;A) Serous drainage&#10;B) Purulent drainage&#10;C) Sanguineous drainage&#10;D) Serosanguineous drainage

Accepted Answer

Purulent is thick,yellow,green,or brown,indicating the presence of dead or living organisms and white blood cells.Serosanguineous is pale,more watery,and a combination of plasma and red cells,which may be blood streaked.Serous is clear,watery plasma.Sanguineous is fresh bleeding.

Question 6

The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone,tendon,or muscle.Which pressure injury stage will be recorded in the patient's chart?&#10;A) Stage 1&#10;B) Stage 2&#10;C) Stage 3&#10;D) Stage 4

Accepted Answer

Stage 3: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage 1: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage 2: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage 4: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling

Question 7

Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery?&#10;A) Mental status and orientation&#10;B) Hourly fluid intake and output&#10;C) Lung sounds and pulse oximetry&#10;D) Presence of peripheral pedal pulses

Accepted Answer

Evaluate the patient's ability to ventilate properly,including deep breathing and coughing.An abdominal binder supports a large incision that is vulnerable to stress when a patient moves or coughs.Mental status,fluid balance,and peripheral pulses are not affected by the abdominal binder.

Question 8

Which statement by the patient indicates that additional teaching is needed about the application of an elastic bandage to the ankle?&#10;A) &#34;I will take the bandage off if my toes start to tingle.&#34;&#10;B) &#34;I need to make sure the bandage is applied smoothly.&#34;&#10;C) &#34;I need to watch my toes for swelling and feeling cold.&#34;&#10;D) &#34;I will to wrap the bandage from my shin toward my toes.&#34;

Accepted Answer

The bandage should be wrapped from the toes up to the shin.The toes must be observed for swelling and the bandage must be applied smoothly.The bandage should be removed if the toes start to tingle.

Question 9

The nurse is caring for a patient with a puncture wound.How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

A) 1 year
B) 3 years
C) 5 years
D) 10 years

Accepted Answer

When an injury results from trauma from a dirty penetrating object,determine if the patient has received a tetanus toxoid injection within the last 10 years.Within the past year,3 years,or 5 years is too early.

Question 10

The patient has a large red,blistered area on the left hip.Which pressure injury stage will be recorded in the patient's chart?&#10;A) Stage 1&#10;B) Stage 2&#10;C) Stage 3&#10;D) Stage 4

Accepted Answer

Stage 2: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage 1: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage 3: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage 4: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling

Question 11

The patient's sacral pressure injury is open with exposed bone.Which pressure injury stage will be recorded in the patient's chart?&#10;A) Stage 1&#10;B) Stage 2&#10;C) Stage 3&#10;D) Stage 4

Accepted Answer

The answer of The patient's sacral pressure injury is open...

Question 12

Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury?&#10;A) Serum total protein level of 4.6 g/dL&#10;B) Braden Scale score of 22&#10;C) Cetirizine 5 mg PO daily&#10;D) Fasting serum glucose level 84 mg/dL

Accepted Answer

The answer of Which assessment finding indicates to the nurse...

Question 13

Which assessment charting indicates that the wound is healing by primary intention?&#10;A) The 4-inch incision edges are well approximated with intact sutures.&#10;B) Ulcerated 3-inch &#215; 1-inch area has thick yellow slough present in the center.&#10;C) Incision is 5 inch long &#215; 1 inch deep &#215; 1 inch wide with granulation tissue present.&#10;D) Superficial 3-inch &#215; 3-inch abrasion has no active bleeding,drainage or debris.

Accepted Answer

The answer of Which assessment charting indicates that the wound...

Question 14

Which factor contributes to pressure injury formation when patient's body slides downward to the foot of the bed?&#10;A) Momentum&#10;B) Acceleration&#10;C) Applied force&#10;D) Shearing force

Accepted Answer

The answer of Which factor contributes to pressure injury formation...

Question 15

The patient's incision is fading to a pale pink following surgery 2 months previously.Which stage of the healing describes the current status of the patient's wound?&#10;A) Hemostasis phase&#10;B) Remodeling phase&#10;C) Proliferative phase&#10;D) Inflammation phase

Accepted Answer

The answer of The patient's incision is fading to a...

Question 16

The patient has a nonblanchable area of redness on the right malleolus.Which pressure injury stage will be recorded in the patient's chart?&#10;A) Stage 1&#10;B) Stage 2&#10;C) Stage 3&#10;D) Stage 4

Accepted Answer

The answer of The patient has a nonblanchable area of...

Question 17

Which is the first intervention of the nurse for changing the dressing to a painful burn?&#10;A) Administer pain medication 30 minutes beforehand.&#10;B) Gently irrigate the wound using sterile normal saline.&#10;C) Loosen the tape gently by pressing the skin away from it.&#10;D) Observe the wound bed for presence of granulation tissue.

Accepted Answer

The answer of Which is the first intervention of the...

Question 18

The nurse is caring for a patient who has perineal skin breakdown after sitting in wet underclothes for many hours.Which term will be used to document the patient's condition in the medical record?&#10;A) Maceration&#10;B) Dehiscence&#10;C) Evisceration&#10;D) Debridement

Accepted Answer

The answer of The nurse is caring for a patient...

Question 19

Which patient would benefit from soaking in a sitz bath?&#10;A) A patient with an abscessed tooth&#10;B) A patient with a fractured right arm&#10;C) A patient with painful back muscle spasms&#10;D) A patient who just had hemorrhoid surgery

Accepted Answer

The answer of Which patient would benefit from soaking in...

Question 20

Which intervention will the nurse use for an abscessed leg wound?&#10;A) Warm water sitz baths&#10;B) Cold moist compresses&#10;C) Warm moist compresses&#10;D) Epsom salt solution soaks

Accepted Answer

The answer of Which intervention will the nurse use for...

Question 21

The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue.Which term will the nurse use to describe the ulcer in the patient's medical record?&#10;A) Fluctuant&#10;B) Indurated&#10;C) Macerated&#10;D) Unstageable

Accepted Answer

The answer of The patient has a deep decubitus ulcer...

Question 22

A postoperative abdominal surgery patient has been admitted to the surgical floor.The nurse is aware that wound healing is delayed due to complications.Which conditions would prevent normal wound healing at the surgical site?

A) Dehiscence
B) Evisceration
C) Debridement
D) Hemostasis
E) Hemorrhage

Accepted Answer

The answer of A postoperative abdominal surgery patient has been...

Question 23

On admission a patient is noted to have an alteration in skin integrity on the right heel.The nurse uses the Braden Scale.Which areas will the nurse assess when using this scale?&#10;A) Mobility&#10;B) Nutrition&#10;C) Infection&#10;D) Activity&#10;E) Friction

Accepted Answer

The answer of On admission a patient is noted to...

Question 24

Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired skin integrity related to immobility and muscle weakness?&#10;A) The patient's skin will remain intact without redness or ulceration.&#10;B) The nurse will assess the patient's skin daily for any sign of breakdown.&#10;C) The patient will verbalize at least two methods to prevent skin breakdown.&#10;D) The patient's wounds will be kept clean and will not develop signs of infection.&#10;E) The nurse will reposition the patient every 2 hours and pad bony prominences.

Accepted Answer

The answer of Which outcomes are appropriate for the patient...

Question 25

The patient just sustained a deep laceration that is bleeding profusely.Which stage of healing describes the current state of the patient's wound?&#10;A) Hemostasis phase&#10;B) Proliferative phase&#10;C) Inflammation phase&#10;D) Remodeling phase

Accepted Answer

The answer of The patient just sustained a deep laceration...

Deck 38: Skin Integrity and Wound Care