Deck 36: Skin Integrity Wound Healing

Question 1

Pressure ulcers are directly caused by which condition at the site?

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

Answer 1

Compromised blood flow

Question 2

A patient is recovering from surgery for a ruptured appendix.Because the surgeon did not surgically close the wound,what wound healing process will occur?

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

Answer 2

Secondary intention

Question 3

A patient has a pressure injury on the coccyx measuring 5 cm by 3 cm that is covered with eschar.How should the nurse classify this wound?

A) Stage 2 pressure injury
B) Stage 3 pressure injury
C) Stage 4 pressure injury
D) Unstageable pressure injury

Answer 3

Unstageable pressure injury

Question 4

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 5

Which is a characteristic of chronic wounds?

A) Are full-thickness wounds
B) Result from pressure
C) Are usually infected
D) Exceed the typical healing time

Question 6

Three days after abdominal surgery,the nurse notes 4-cm periwound erythema and swelling at the distal end of a client's incision.The area is tender and warm to the touch.Staples are intact along the incision,and there is no obvious drainage.Heart rate is 96 beats/min and oral temperature is 100.8°F (38.2°C).What kind of complication should the nurse suspect this client is experiencing?

A) Infection at the incisional site
B) Dehiscence of the wound
C) Hematoma under the skin
D) Formation of granulation tissue

Question 7

A patient with quadriplegia has an ischial wound that extends through the epidermis into the dermis.How should the nurse document the depth of this wound?

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

Question 8

A client developed a stage 4 pressure injury to the sacrum 6 weeks ago,and now the ulcer appears to be a shallow crater involving only partial skin loss.How should the nurse now classify this pressure injury?

A) Stage 1 pressure injury,healing
B) Stage 2 pressure injury,healing
C) Stage 3 pressure injury,healing
D) Stage 4 pressure injury,healing

Question 9

A client requires sedation,intubation,and mechanical ventilation for 2 weeks.What would be an appropriate nursing diagnosis for the client?

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 10

A patient with underlying cardiac disease and a draining wound requires careful monitoring of fluid balance.Which method for evaluating 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 11

When teaching a patient about the healing process of an open wound after surgery,which point should 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 for a wound closed at surgery.
D) The patient should expect to remain hospitalized until complete wound healing occurs.

Question 12

While assessing a new wound,the nurse notes red,watery drainage.What type of drainage will the nurse document this as?

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

Question 13

Which is an applicable goal/outcome for the client with a stage 4 pressure injury?

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 14

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

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

Question 15

A patient has a stage 1 pressure injury on the left heel.What is the initial treatment for this pressure ulcer?

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

Question 16

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) Client completes antibiotic treatment as ordered.
C) The wound will remain free of scar tissue at healing.
D) Client increases caloric intake throughout the healing process.

Question 17

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 18

Which statement 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.

Question 19

What impact does hypertensive medication have on skin integrity and wound healing?

A) Causes cellular toxicity
B) Increases the risk of ischemia
C) Delays wound healing
D) Predisposes to hematoma formation

Question 20

Which outcome indicates that the plan of care for a client with diabetes and severe peripheral neuropathy was effective?

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 21

A patient has multiple open wounds that require treatment.What should the nurse do when performing dressing changes?

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 22

Which process occurs during the inflammatory phase of wound healing? Select all that apply.

A) Granulation
B) Hemostasis
C) Epithelialization
D) Inflammation
E) Collagen formation

Question 23

Which is a risk assessment tool 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
E) Glasgow scale

Question 24

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 25

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
E) Used to determine the amount of scarring

Question 26

A patient has a stage 2 pressure injury that 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 27

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 28

When would the nurse know that care provided to a stage 2 pressure injury has been effective?

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 29

A patient recovering from abdominal surgery has an 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,what would be appropriate to apply?

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

Question 30

The nurse learns that a patient's wound will be sutured closed after additional healing occurs.Which type of healing is occurring with this wound?

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

Question 31

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 32

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

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 33

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) Actively bleeding
B) Swollen,tender insect bite
C) Sprained ankle
D) Lower back pain

Question 34

A 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.Which would be an appropriate dressing choice?

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

Question 35

A patient has an area of nonblanchable erythema on his coccyx.What would be the most important treatment for this patient's stage 1 pressure injury?

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

Question 36

Which is an example of a nonselective mechanical débridement method? Select all that apply.

A) Wet-to-dry dressings
B) Sharp débridement
C) Whirlpool
D) Pulsed lavage
E) Enzymes