Ch. 48 Skin integrity and Wound Care

A nurse is teaching a student nurse about the dermis. Which statement shows education has been effective? "The dermis is comprised of dead skin cells." "Sebaceous glands are located in the dermis." "Rete ridges allow the dermis and epidermis to slide." "The dermis is the same thickness everywhere on the body."

"Sebaceous glands are located in the dermis."

How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing? 15-20 kcal 20-25 kcal 25-30 kcal 30-35 kcal

30-35 kcal

Which method of wound debridement is the slowest? Sharp Biologic Autolytic Mechanical

Autolytic

Blanket suture

a continuous self-locking stitch.

Continuous sutures

a series of stitches, but they are not individually knotted.

Retention sutures

are placed more deeply than skin sutures

Braden scale

Ranks patients on risk categories of sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Score lower than 18 places the patient at risk for pressure ulcer development. If the patient scores particularly low in one or more categories, preventive strategies can be directed more precisely at those specific areas to decrease overall risk.

Intermittent sutures

each individual suture is made in the skin.

The student nurse is discussing skin integrity with a patient who has a closed wound. Which statement made by the student nurse indicates teaching has been effective? "A closed wound indicates that your skin is not intact." "A closed wound indicates you have a benign condition." "A closed wound indicates an actual break in the skin's surface." "A closed wound indicates that underlying tissue damage may still exist."

"A closed wound indicates that underlying tissue damage may still exist."

A nurse educator has just finished teaching a lesson about types of wound dressing. Which student statement about alginate dressings indicates understanding of the lesson? "Alginate dressings are adhesive." "Alginate dressings are occlusive." "Alginate dressings add moisture to wounds." "Alginate dressings are produced from brown seaweed."

"Alginate dressings are produced from brown seaweed."

A patient who was recently diagnosed with diabetes mellitus asks the student nurse why diabetes mellitus affects skin integrity and healing. Which response by the student nurse indicates effective learning? "Diabetes mellitus causes changes to the nervous system." "Diabetes mellitus causes changes to the digestive system." "Diabetes mellitus causes changes to the pulmonary system." "Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems."

"Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems." Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems, which decreases blood flow to the wound. Decreased blood flow decreases the supply of nutrients and oxygen to the wound, thereby affecting skin healing.

The nurse is caring for a patient with a contaminated wound that was initially left open for a while after surgery. What is the most appropriate explanation of tertiary intention that the nurse makes to the patient? "The wound will be closed later when the infection risk is reduced." "The wound does not need to be closed if it was initially left open." "The wound will be left open for observation and not closed at all." "The wound is being observed for drainage because of the cause of the surgery."

"The wound will be closed later when the infection risk is reduced."

The registered nurse is teaching the student nurse about delayed wound healing. Which statement made by the student nurse indicates a need for further teaching? "Wounds are at risk for infection by some types of drugs, such as steroids." "Wounds should be kept wet and moist to prevent skin tissue from tightening." "Wounds may have a delayed healing time caused by nutritional deficiencies." "Wounds are made worse by external forces against the skin, such as pressure or friction."

"Wounds should be kept wet and moist to prevent skin tissue from tightening."

What amount of zinc is recommended for wound healing? 15-30 mg 30-50 mg 25-60 mg 50-70 mg

15-30 mg

What amount of retinol equivalents for vitamin A per day should the nurse recommend a patient to consume to support proper wound healing? 1200-1400 1400-1500 1500-1600 1600-2000

1600-2000

According to the Braden scale, a score lower than________ places a person at risk for pressure sore development.

18

What amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing? 15-20 mL 20-25 mL 25-30 mL 30-35 mL

30-35 mL

An adult male patient presents to the ER, suffering from a traumatic brain injury after having been in a bad car accident. He is unconscious, incontinent of both urine and stool. According to the Norton Scale, the nurse realizes this places him at great risk for skin breakdown. What is this patient's Norton Scale score? 10 8 5 20

5

What is a fistula? Muscular layer of tissue that forms after wound healing. Connection of blood vessels that form after an incision heals. Connection between two areas of the body by the nervous system. Abnormal connection between two internal organs or between protruding internal organ and the outside of the body.

Abnormal connection between two internal organs or between protruding internal organ and the outside of the body. A fistula is an abnormal connection between two internal organs or between protruding internal organ and the outside of the body.

Which cleaners harm cells and can delay healing? Select all that apply. Acetic acid Dakin's solution Povidone-iodine Hydrogen peroxide Normal saline 0.9%

Acetic acid Dakin's solution Povidone-iodine Hydrogen peroxide

Norton scale

Ranks risk based on the patient's physical condition, mental state, activity, mobility, and continence. Lower score indicates higher risk. Understanding definitions of different categories is essential for arriving at a risk score that is reflective of actual risk.

The nurse is providing care to a patient with a pressure ulcer that is covered in eschar. Which dressing prescription will the nurse use for this patient? None Adherent film Composite film Calcium alginate

Adherent film A pressure ulcer covered in eschar is an unstageable pressure ulcer. The nurse would use an adherent film dressing because it will facilitate softening of the eschar to allow for debridement. No dressing is appropriate for an intact stage I pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer. A calcium alginate dressing is appropriate for a clean stage III or stage IV pressure ulcer.

A nurse is caring for pediatric patient with a bleeding, infected thoracic gunshot wound. What dressing combination is best for the nurse to apply? Alginate and foam Transparent and gel Hydrocolloid and foam Hydrocolloid and gauze

Alginate and foam

A nurse is teaching a group of older adults about skincare. A student asks the nurse what causes freckles? What would be an accurate response? An overproduction of collagen A stiffening of the epidermal tissue An uneven distribution of melanin Weakened blood vessels in the skin

An uneven distribution of melanin

Which adjuvant treatments are only considered for patients diagnosed with clean stage IV or unstageable pressure ulcers? Support hydration Nutritional support Surgical consultation for closure Surgical consultation for debridement Evaluation of pressure-redistribution needs

Surgical consultation for closure Surgical consultation for debridement

A nurse is caring for an under-nourished 16-month-old who is immobile and has a critical respiratory infection. Which intervention related to skin hygiene is appropriate for the patient? Bathe with hot water and soap. Apply moisture barrier to buttocks. Protect skin from contact with blood. Keep skin folds dry from perspiration.

Apply moisture barrier to buttocks.

A nurse is caring for a patient with a continually draining surgical wound. Which interventions should the nurse perform to prevent skin complications? Select all that apply. Cleanse folds in the patient's skin. Assess the wound for excessive exudates. Irrigate wound drainage off the skin immediately. Use soap and hot water to clean and irrigate pressure ulcers. Apply a moisture-barrier ointment to skin around the wound.

Assess the wound for excessive exudates. Irrigate wound drainage off the skin immediately.

Which tasks can be delegated to a family member in regard to skin integrity and wound care? Assisting with hair care Assessing and evaluating a patient's skin and wounds Supervising UAP Deciding which medications the patient will take

Assisting with hair care

The student nurse understands that a patient with enterocutaneous fistula has what type of opening? Between the muscle and the bone Between the skin and the intestines Between the lungs and the diaphragm Between the intestines and the vagina

Between the skin and the intestines An opening between the skin and the intestines is being described by the term "enterocutaneous." Entero means intestines and cutaneous means skin.

Which statement regarding heat and cold therapy is true? Heat therapy causes vasoconstriction. Edema is contraindicated with heat therapy. Cold therapy helps with wound debridement. Bleeding is contraindicated with heat therapy.

Bleeding is contraindicated with heat therapy.

What type of wound drainage is considered sanguineous? Clear, watery plasma Bright red, active bleeding Thick and yellow, green, tan, or brown Pale pink, watery mixture of clear and red fluid

Bright red, active bleeding

Which dressing will the nurse use for a patient with a clean stage III pressure ulcer? None Adherent film Composite film Calcium alginate

Calcium alginate The nurse would use a calcium alginate dressing for a patient with a clean stage III pressure ulcer. No dressing is only appropriate for an intact stage I pressure ulcer. An adherent film dressing is appropriate for an unstageable pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer.

How are wounds classified? Select all that apply. Size Color Cause Depth Presence or absence of infection

Cause Depth Presence or absence of infection

patient with diabetes is being seen in the emergency department for blood sugar issues. What is the most appropriate nursing action in this scenario? Checking the patient's feet Assessing the patient's reflexes Testing the patient's blood pressure Asking the patient about financial and insurance information

Checking the patient's feet

A nurse is working in the emergency department and a child was brought in with a burn on his arm. Which action made by the nurse demonstrates appropriate wound classification? Classifying the wound according to color. Classifying the wound according to the source of burn. Classifying the wound according to the degree of burn. Classifying the wound according to contamination factor.

Classifying the wound according to the degree of burn.

The nurse is preparing to clean and irrigate traumatic wounds on her patient's right leg and right arm. What should the nurse do? Clean with acetic acid and irrigate very gently. Clean with Dakin's solution and irrigate forcefully. Clean with hydrogen peroxide and irrigate with cold normal saline 0.9%. Clean with normal saline 0.9% and irrigate with room temperature normal saline 0.9%.

Clean with normal saline 0.9% and irrigate with room temperature normal saline 0.9%.

A nurse is preparing to perform vacuum-assisted wound closure. Which items does the nurse need? Select all that apply. Gauze Clear drape Suction tubing Foam dressing Negative-pressure setting device

Clear drape Suction tubing Foam dressing Negative-pressure setting device

Which action is involved in safely removing retention sutures? Cut the suture at the end nearest to the knot. Cut the suture as farthest to the skin edge as possible. Pull the visible part of the suture above the skin through underlying tissue. Clip suture materials nearest to the skin edge on one side, and pull from the other side.

Clip suture materials nearest to the skin edge on one side, and pull from the other side.

What two primary complications of wound healing can occur when tissues of surgical incisions are under physical stress? Infection and bruising Dehiscence and infection Evisceration and infection Dehiscence and evisceration

Dehiscence and evisceration

What is the advantage of a moist application in wound healing? Does not promote sweating Does not cause skin maceration Retains temperature longer Less risk for burns to the skin than dry applications

Does not promote sweating A warm, moist application does not promote sweating, so it limits unnecessary fluid loss. A dry, not moist, application does not cause skin maceration. Dry, not moist, heat retains temperature longer, because evaporation does not occur. Dry heat carries less risk for burns skin than does moist heat.

What characteristics related to skin may reflect an overall health problem? Select all that apply. Dryness Turgor Wounds Odor Skin tone

Dryness Turgor Wounds Odor

Which factors are related to pressure ulcers? Select all that apply. Duration Obesity Intensity Moisture Immobility

Duration Intensity Moisture Immobility

A patient enters the emergency department with a third-degree burn on his stomach. The patient stated that the burn is painless. Which layer of skin was most likely affected? Epidermis Upper dermis Entire dermis Hypodermis

Entire dermis

A wound care nurse practitioner is examining a patient's decubitus ulcer on the lateral malleolus and suspects that it is an infected decubitus. Which findings would the nurse likely find during the wound assessment? Select all that apply. Erythema noted on the superior portion of the ulcer Purulent, malodorous drainage 1.5 cm wound with serous drainage and tissue epithelialization Temperature of 102° F Patient reports a pain level of 3/10 during the exam

Erythema noted on the superior portion of the ulcer Purulent, malodorous drainage Temperature of 102° F Patient reports a pain level of 3/10 during the exam

A boy is admitted with diffuse abrasions or "road rash" from trauma. Large areas of his epidermis are missing. Which will be affected by these abrasions? Body temperature Fluid and electrolytes Protection over bony prominences Blood supply

Fluid and electrolytes

A patient's wound is producing a moderate amount of drainage. When the patient is in respiratory distress, the wound drainage is excessive. What dressing should the nurse choose for this patient's wound? Gel Foam Transparent Hydrocolloid

Foam

What external forces can result in pressure ulcers? Select all that apply. Friction Massage Pressure Movement Shear force

Friction Pressure Shear force

Pressure ulcer stage 4

Full-thickness wound that is deeper than a stage III wound Involves exposure of muscle, bone, or connective tissue (tendons, cartilage) Infection of the bone, if exposed, is highly likely

Pressure ulcer unstageable

Full-thickness wound with necrotic tissue (eschar) Assessment of wound depth or involvement of underlying tissues is not possible

Pressure ulcer stage 3

Full-thickness wounds extending into the subcutaneous tissue, but not into fascia, muscle or bone May include undermining (tissue loss around edges and under intact skin, forming a lip around the wound) May include tunneling (narrow passage-way extending out from the wound)

A nurse admits a trauma patient and prepares to care for his multiple wounds. Which wound closure materials could the nurse anticipate using? Select all that apply. Glue Staples Steri-Strips Nylon sutures Catgut sutures

Glue Staples Nylon sutures Catgut sutures

Which statement regarding dressings is true? Gauze is an effective barrier against microorganisms. Hydrocolloids are inappropriate for infected wounds. Hydrocolloids have fibers that may slough off into wounds. Transparent dressings are best for wounds with moderate drainage.

Hydrocolloids are inappropriate for infected wounds.

Which type of dressing is preferred for dry wounds? Hydrogel Hydrocolloid Calcium alginate Debriding enzymes

Hydrogel

The student nurse is learning how to classify burn wounds. Which statement made by the student nurse reflects a misunderstanding? "I can classify burn wounds according to the depth of the lesion." I can classify burn wounds according to the depth and width of the lesion." "The wound cannot be classified according to what caused the burn lesion." "The wound cannot be classified according to the resulting damage to the epidermis."

I can classify burn wounds according to the depth and width of the lesion." Burn wounds are not classified according to how wide the lesion is, so this statement shows a misunderstanding on the part of the student nurse.

A patient has a pressure ulcer through all layers of the epidermis with the dermis exposed. Due to the ulcerated epidermis, what will be compromised? Blood supply to the skin Temperature regulation Protection over bony prominences Immune response

Immune response

3 phases of wound healing

Inflammatory phase, which includes homeostasis Proliferative phase Maturation phase (remodeling)

Pressure ulcer stage 1

Intact, non-blistered skin Non-blanchable erythema or persistent redness in the area of pressure (abnormal reactive hyperemia) Painful area that differs in firmness and temperature from surrounding tissues

Which statement is true about the skin? It has no role in body temperature. It is closely linked to personal identity. It has nothing to do with cultural identity. It alerts to danger through electrolyte balance.

It is closely linked to personal identity.

What are the steps involved in wound undermining? Select all that apply. Laterally insert the cotton tipped applicator into the widest section. Mark the area on the stick end of the applicator that is even with the edges of the skin. Administer pain medication. Measure the distance from the top of the applicator to the marked are to determine depth. Measure any changes in the surrounding skin that may indicate infection.

Laterally insert the cotton tipped applicator into the widest section. Mark the area on the stick end of the applicator that is even with the edges of the skin. Administer pain medication. Measure the distance from the top of the applicator to the marked are to determine depth.

An adult patient recently had a partial gastrectomy. At present, the patient is NPO and receives total parenteral nutrition (TPN). Using the Braden Scale, what would be the expected level of the patient's nutritional status? Level four or excellent Level two or probably inadequate Level one or very poor Level three or adequate

Level three or adequate

In a focused wound assessment, what data should be collected? Select all that apply. Location and size Presence of tunneling Pain tolerance Drainage Wound bed, edges, and surrounding tissues

Location and size Presence of tunneling Drainage Wound bed, edges, and surrounding tissues

Which are potential skin complications for a patient with a continually-draining surgical wound? Select all that apply. Rash Maceration Dehiscence Skin infection Pressure ulcers

Maceration Dehiscence Skin infection Pressure ulcers

A nurse is caring for a patient with deep partial-thickness burns. The patient was admitted to the hospital 18 hours ago and sustained the injury 20 hours ago. Which nursing actions are most important during this stage of wound care? Select all that apply. Maintaining airway Controlling chronic pain Applying prescribed topical medications Preventing fluid and electrolyte imbalance Implementing measures to preserve function

Maintaining airway Applying prescribed topical medications Preventing fluid and electrolyte imbalance

A nurse is caring for an older adult male with a sacral decubitus. The nurse is required to measure the dimensions of the wound. Which steps would the nurse take? Select all that apply. Measure the depth by inserting the end of a sterile cotton-tipped applicator down into the deepest portion of the wound. Measure the width laterally from left to right at the widest portion of the wound. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. Measure the length vertically from the top to the bottom at the widest open area of the wound. Measure the width laterally by measuring the smallest portion of the wound from left to right.

Measure the depth by inserting the end of a sterile cotton-tipped applicator down into the deepest portion of the wound. Measure the width laterally from left to right at the widest portion of the wound. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. Measure the length vertically from the top to the bottom at the widest open area of the wound.

Which factors affect skin integrity? Select all that apply. Medications Vascular diseases Excessive dryness Nutritional deficits Darkness exposure

Medications Vascular diseases Nutritional deficits

An adolescent expresses concern to the nurse about how she will look in a bathing suit after her leg wound heals. Which primary goal of wound closure is the patient most concerned about? Prevention of pain Prevention of infection Minimization of scarring Minimization of ecchymosis

Minimization of scarring

Which action is inappropriate for maintaining an airtight seal in negative-pressure wound therapy? Avoiding adhesive removers Moistening the periwound area thoroughly Framing the periwound area with skin sealant Filling uneven skin surfaces with a skin-barrier product

Moistening the periwound area thoroughly To maintain an airtight seal, the periwound area should be dried thoroughly, not moistened. The remaining actions are appropriate. Adhesive removers should be avoided because they leave a residue that hinders film adherence. The periwound area should be framed with skin sealant. Uneven skin surfaces should be filled with skin-barrier products.

Which statement regarding burn care is true? Antibiotic ointment should be avoided. The burn should be cleaned with alcohol. The burn should be cooled to concentrate heat. NSAIDs or a narcotic should be administered for pain.

NSAIDs or a narcotic should be administered for pain.

What is embedded in the dermis? Select all that apply. Nerves Fat tissue Lymphatics Sweat glands Hair and nail follicles

Nerves Lymphatics Sweat glands Hair and nail follicles

A nurse is preparing to clean a wound bed and wants to avoid cell damage. Which solution should the nurse select? Dakin's solution Povidone-iodine Hydrogen peroxide Normal saline 0.9%

Normal saline 0.9%

A nurse is preparing to irrigate a wound. What should the nurse consider? Irrigation fluid should be cold. Normal saline 0.9% is an effective irrigate solution. Forceful irrigation is necessary to thoroughly clean wounds. Irrigating a wound can decrease leukocyte activity, promoting healing.

Normal saline 0.9% is an effective irrigate solution.

The nurse is classifying a wound in her chart. The nurse understands that which documentation would be a standard classification that other health care workers would be able to comprehend? Slice wound that is very dirty Open wound with raised scar tissue Round wound with purulent drainage Open knife wound with contamination

Open knife wound with contamination An open knife wound with contamination is documentation that others would comprehend, as wounds are classified by cause (in this case a knife), as well as whether they are contaminated.

A patient has a decubitus ulcer that is 1 cm deep and 2 cm wide by 3 cm long. The nurse notices the superior margin of the wound has significant undermining. How can the nurse describe "undermining" to the patient's family so they have a better understanding of the wound? A deeper area of an ulcer caused by a high volume of pressure forced upon tissue layers, creating a sink-hole-like effect in the wound. Overhanging skin edges at the margin of the wound; in essence, the pressure ulcer is larger at its base compared to the skin surface. A form of cell injury which results in the premature death of cells in living tissue by autolysis. The act of shedding or casting off dead tissue.

Overhanging skin edges at the margin of the wound; in essence, the pressure ulcer is larger at its base compared to the skin surface.

A patient is recovering from surgery. After the sixth day of recovery, which action made by the nurse indicates proper assessment of how the patient's incision is healing? Asking the patient if any pain is felt Charting the incision line's color and tenderness Removing all sutures and stables around the wound Palpating the area of induration next to the incision line

Palpating the area of induration next to the incision line

Dehiscence

Partial or complete separation of tissue layers

Pressure ulcer stage 2

Partial-thickness wound involving the epidermis and dermis Shallow and superficial with a pink wound bed Also includes intact or ruptured blisters from pressure that have not yet cratered

How does sensory loss relate to the formation of a pressure ulcer? Patients may be at risk of too much friction. Patients may be unable to feel pain or discomfort. Patients may be unable to detect the onset of malnutrition. Patients may be unable to notice the warning signs of maceration.

Patients may be unable to feel pain or discomfort.

The nurse is caring for an older adult patient in a sub acute rehab setting who recently suffered a cerebral vascular accident (CVA) and has a right hemiparesis. The patient requires maximum assistance for repositioning in the bed wheelchair. According to the Braden Scale, the patient's risk for shearing and friction falls into which category? No apparent problem, or level three Potential problem, or level two Problem, or level one Potential problem, or level three

Potential problem, or level three

A nurse is caring for an adolescent patient with asthma who is able to ambulate. Which aspect of skin hygiene should the nurse focus on for this patient? Preventing perspiration Limiting skin exposure to stool Limiting skin exposure to urine Preventing use of a moisturizer

Preventing perspiration

The nurse is caring for a patient with a recent, minor injury. As the nurse assesses the site of the injury, she notes that the new tissue has a granular, bumpy texture. The patient reports that the injured site still "bleeds easily." The nurse understands the phase of wound healing by documenting which stage in the patient's chart? Maturation Unstageable Proliferative Inflammatory

Proliferative The proliferative phase is the phase of healing and repair, in which new tissue bleeds easily and has a granular and bumpy texture. This is correctly observed in the patient in this scenario.

The nurse tells the patient he will be turned every two hours to keep his skin from "breaking down" and causing infection. The nurse knows that intact skin supports which function of the skin? Production of Vitamin D Release of toxins Regulation of heat Protection

Protection

Which are functions of the basale layer of the epidermis? Select all that apply. Helps produce friction and shear. Provides skin coloring and protects it from ultraviolet light. Produces new cells that push through to the stratum corneum. Gives the skin strength and flexibility and allows it to repair itself. Helps provide environmental protection and regulates fluids and electrolytes.

Provides skin coloring and protects it from ultraviolet light. Produces new cells that push through to the stratum corneum. Gives the skin strength and flexibility and allows it to repair itself.

Which of a novice nurse's actions would necessitate intervention when providing care for a patient who is prescribed negative-pressure wound therapy? Retaining hair around the wound Using a skin barrier around the wound Drying around the wound thoroughly Filling uneven wound surfaces with a hydrocolloid product

Retaining hair around the wound Retaining hair around the wound edges can cause an air leak, so this action requires correction. Using a skin barrier, drying around the wound thoroughly, and filling uneven wound surfaces with a hydrocolloid product are all appropriate and will help maintain an airtight seal.

A patient has a post-operative follow-up appointment with the nurse. During the appointment, the nurse removes the patient's dressing and observes that the wound appears infected. Which action by the nurse demonstrates proper knowledge of wound healing and skin integrity? Assessing the patient's appetite Reviewing the patient's medications Checking the patient for signs of exhaustion Asking the patient about stressors in the home

Reviewing the patient's medications

Which are benefits of using a binder over or around a dressing? Securing a splint Reducing edema Allowing the body part freedom to move Creating pressure over the body part Preventing infection

Securing a splint Reducing edema Creating pressure over the body part

A nurse is performing debridement for a patient with hemophilia. Which type of debridement especially requires caution for this patient? Sharp Biologic Autolytic Enzymatic

Sharp

What is characteristic of stage III pressure ulcers? Underlying muscle is exposed Slough may be present with slough, but it does not obscure the depth of tissue loss. Discoloration of the skin, warmth, edema, hardness, and/or pain may be present. It presents as a shallow, open ulcer with a red-pink wound bed without slough.

Slough may be present with slough, but it does not obscure the depth of tissue loss.

A nurse is caring for a patient with paralysis who has a full-thickness wound that extends into the subcutaneous tissue, but not into the fascia, muscle, or bone. The nurse demonstrates knowledge of wound classification by documenting the pressure ulcer as which stage? Stage I Stage II Stage III Stage IV

Stage III

Which pressure ulcer is expected to heal through granulation and reepithelialization? Stage I Stage II Stage IV Unstageable

Stage IV Stage IV pressure ulcers are expected to heal through granulation and reepithelialization. Wound care for a stage I pressure ulcer is aimed at slow healing without epidermal loss over 7 to 14 days. Stage II pressure ulcers are expected to heal through reepithelialization. Wound care for an unstageable pressure ulcer includes debridement done to soften the eschar.

A patient presents to the emergency department with a superficial, non-contaminated wound that occurred within the last hour. Which type of wound closure is most appropriate for this patient? Gauze Staples Sutures Steri-Strips

Steri-Strips

What are primary sources of contamination for skin? Select all that apply. Stool Urine Blood Perspiration Wound drainage

Stool Urine Perspiration Wound drainage

The nurse is careful to elevate her patient's head of bed 30 degrees and uses a draw sheet to move her patient. In doing these things, she is protecting which layers of the epidermis? Stratum corneum and stratum lucidum Stratum lucidum and stratum germinavatum Stratum germinavatum and stratum spinosum Stratum lucidum and stratum spinosum

Stratum lucidum and stratum spinosum

Which statements are true about superficial- or partial-thickness wounds? Select all that apply. These wounds tend to heal quickly. These wounds affect only the dermis. Superficial wounds affect only the epidermis. These wounds usually take a very long time to heal. Partial-thickness wounds affect the epidermis and the dermis, but do not extend through the dermis to the subcutaneous layer.

These wounds tend to heal quickly. Superficial wounds affect only the epidermis. Partial-thickness wounds affect the epidermis and the dermis, but do not extend through the dermis to the subcutaneous layer.

Evisceration:

Total separation of tissue layers, allowing protrusion of visceral organs through incision

Which instruction for turning and positioning is correct? Turn patient every 2 hours; elevate head of bed 30 degrees Turn patient every 4 hours; elevate head of bed 30 degrees Turn patient every 2 hours; elevate head of bed 45 degrees Turn patient every 4 hours; elevate head of bed 45 degrees

Turn patient every 2 hours; elevate head of bed 30 degrees

Which nursing action is appropriate when providing care to a patient who exhibits no risk for skin breakdown? Using a standard surface Using a pillow under the calves Using an active support surface Using a pressure-redistribution seat cushion

Using a standard surface

Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis? Zinc Protein Vitamin C Vitamin A

Vitamin A

The absence of adequate amounts of which nutrient in the diet may impair inflammatory response in wound healing? Zinc Proteins Vitamin A Vitamin C

Vitamin A Vitamin A plays a major role in the inflammatory response in wound healing, so a lack of it can impair the inflammatory response. Zinc plays a role in collagen formation and protein synthesis during wound healing. Proteins promote fibroplasia, angiogenesis, collagen formation, and immune function during wound healing. Vitamin C promotes collagen synthesis and capillary wall integrity, and provides antioxidant benefits to support wound healing.

An older adult patient is being treated for edema in the feet. Which therapy is most appropriate for the patient? Warm Sitz bath Warm moist soak Warm moist compress Warm aquathermia pads

Warm moist soak

Which tools may be used to track wound healing? Select all that apply. Braden Scale Wound Characteristic Instrument Norton Scale Pressure Sore Status Tool (PSST) Pressure Ulcer Scale for Healing (PUSH) tool

Wound Characteristic Instrument Pressure Sore Status Tool (PSST) Pressure Ulcer Scale for Healing (PUSH) tool