Deck 31: Skin Integrity and Wound Care

Question 1

The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information?

A) Question the physician about the accuracy of this agent.
B) Refuse to use 0.9% normal saline on a wound.
C) Document the rationale for not changing the dressing.
D) Continue with the dressing change as planned.

Answer 1

Continue with the dressing change as planned.

Question 2

Which is an example of a closed wound?

A) Abrasion
B) Ecchymosis
C) Incision
D) Puncture wound

Answer 2

Ecchymosis

Question 3

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?

A) Self-care Deficit
B) Risk for Imbalanced Nutrition
C) Anxiety
D) Risk for Infection

Answer 3

Risk for Infection

Question 4

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings?

A) Change position at least once each shift.
B) Implement a turning schedule every two hours.
C) Use ring cushions for heels and elbows.
D) Do not turn; use pressure-relieving support surface.

Question 5

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first?

A) Perform hand hygiene.
B) Insert a swab into the wound at 90 degrees.
C) Measure the width of the wound with a disposable ruler.
D) Assess the condition of the visible wound bed.

Question 6

A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

A) Administer pain medications on a p.r.n. and regular basis.
B) Assist in moving to prevent strain on the suture line.
C) Tell the client that a mild fever is a normal response.
D) If a scar forms over a joint, it may limit movement.

Question 7

What are the two major processes involved in the inflammatory phase of wound healing?

A) Bleeding is stimulated, epithelial cells are deposited
B) Granulation tissue is formed, collagen is deposited
C) Collagen is remodeled, avascular scar forms
D) Blood clotting is initiated, WBCs move into the wound

Question 8

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound?

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

Question 9

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following?

A) Covering the wound area with sterile towels moistened with sterile 0.9% saline
B) Closing the wound area with Steri-Strips
C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze
D) Holding the wound together until the physician arrives

Question 10

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?

A) Clear, watery blood
B) Large numbers of red blood cells
C) Mixture of serum and red blood cells
D) White blood cells, debris, bacteria

Question 11

The nurse would recognize which of these devices as an open drainage system?

A) Penrose drain
B) Jackson-Pratt drain
C) Hemovac
D) Negative pressure dressing

Question 12

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?

A) "I will drink a lot of orange juice and drink milk, too."
B) "I will take the zinc supplement the doctor recommended."
C) "I will restrict my diet to fats and carbohydrates."
D) "I will drink 8 to 10 glasses of water every day."

Question 13

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections?

A) Taking medications as prescribed
B) Proper intake of food and fluids
C) Thorough hand hygiene
D) Adequate sleep and rest

Question 14

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

A) "Oh, for gosh sakes…it doesn't look that bad!"
B) "I understand, but you are going to have to look someday."
C) "I respect your wish not to look at it right now."
D) "You won't be able to go home until you look at it."

Question 15

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

A) Proliferation phase
B) Hemostasis
C) Inflammatory phase
D) Maturation phase

Question 16

A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the client indicates the need for further education?

A) "I understand the rebound effect of heat."
B) "I will put the heat packs only on the sore on my leg."
C) "I will only leave the heat packs on for 20 minutes."
D) "I will leave the heat packs on for an hour."

Question 17

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

A) Document the assessments and intervention.
B) Reinforce the dressing with additional layers.
C) Administer pain medications intramuscularly.
D) Notify the physician and prepare for surgery.

Question 18

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care?

A) An infant
B) A young adult
C) A middle adult
D) An older adult

Question 19

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected?

A) Full-thickness skin loss
B) Skin pallor
C) Blister formation
D) Eschar formation

Question 20

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk?

A) A client 83 years of age who is mobile
B) A client 92 years of age who uses a walker
C) A client 75 years of age who uses a cane
D) A client 86 years of age who is bedfast

Question 21

Which of the following are functions of the skin? Select all that apply.

A) Protection
B) Temperature regulation
C) Sensation
D) Vitamin C production
E) Immunological

Question 22

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply.

A) Constricts peripheral blood vessels
B) Reduces muscle spasms
C) Increases blood flow to tissues
D) Increases the local release of pain-producing substances
E) Reduces the formation of edema and inflammation

Question 23

An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what?

A) Beta-hemolytic streptococcus
B) Age
C) Venous insufficiency
D) Hemangioma

Question 24

Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound?

A) Do not use irrigation to clean the wound before changing the dressing.
B) Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it.
C) Exert light pressure to pack the wound tightly with moistened dressing.
D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.

Question 25

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound?

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

Question 26

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?

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

Question 27

Which of the following is an indication for the use of negative pressure wound therapy?

A) Bone infections
B) Malignant wounds
C) Wounds with fistulas to body cavities
D) Pressure ulcers

Question 28

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record?

A) A clean separation of skin and tissue with a smooth, even edge
B) A separation of skin and tissue in which the edges are torn and irregular
C) A wound in which the surface layers of skin are scraped away
D) A shallow crater in which skin or mucous membrane is missing

Question 29

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client?

A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin.
B) Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
C) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or cooler as compared with adjacent tissue.
D) Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

Question 30

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following?

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

Question 31

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client?

A) Secure the heating pad to the client's clothing with safety pins.
B) Place a heavy towel or blanket over the heating pad to maximize heat effects.
C) Use a heating pad with a selector switch that can be turned up by the client if needed.
D) Place a heating pad anteriorly or laterally to, not under, the body part.

Question 32

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do?

A) Provide total physical hygiene, including perineal care.
B) Provide total physical hygiene, excluding hair care.
C) Provide supplies and orient to the bathroom.
D) Provide supplies and assist with hard-to-reach areas.

Question 33

Which of the following clients would be considered at risk for skin alterations? Select all that apply.

A) A teenager with multiple body piercings
B) A homosexual in a monogamous relationship
C) A client receiving radiation therapy
D) A client undergoing cardiac monitoring
E) A client with diabetes

Question 34

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound?

A) Saline-moistened dressing
B) Dressing secured with Montgomery straps
C) Hydrocolloid dressing
D) Foam dressing