Principles of Wound Care
During which stage of healing does granulation tissue form and epithelialization occur? A. The maturation phase B. The epithelial closure phase C. The inflammatory phase D. The proliferative phase
Correct answer D: during the proliferative stage of wound healing, granulation tissue forms and epithelialization occurs. In the final maturation phase (Option A), collagen reorganizes and strengthens. In the epithelial closure phase (Option B), the wound contracts and begins to close. The inflammatory phase (Option C) starts right after injury and doesn't involve granulation tissue formation or epithelialization.
After assessing a patient's pressure ulcer, you note that subcutaneous fat is visible but that bone, tendon, and muscle are not exposed. You observe slough, but it does not obscure the depth of tissue loss. You also note some undermining and tunneling. What stage pressure ulcer is this? A. Stage II B. Suspected deep tissue injury C. Stage III D. Stage IV
Correct answer C: A Stage III pressure ulcer involves full-thickness tissue loss, possibly with visible subcutaneous fat by with no exposer of bone, tendon, or muscle; slough may be present but doesn't obscure the depth of tissue loss, and undermining and tunneling may also be present. A Stage II pressure (Option A) involves a partial-thickness tissue loss presenting as a shallow, open ulcer with a red-pink wound bed without slough. A suspected deep tissue injury (Option B) involves a purple or maroon localized area of discolored intact skin or blood-filled blister resulting from damage of underlying soft tissue from pressure, shear, or both. A stage IV pressure ulcer (Option D) involves full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed.
Where is a venous ulcer typically found on a patient? A. The medial lower leg and ankle B. The plantar aspect of foot C. On a bony prominence D. Under the heels
Correct answer A: A venous ulcer is typically found on the medial lower leg and ankle. A diabetic ulcer is usually found on the plantar aspect of the foot (Option B) or under the heels (Option D). A pressure ulcer is usually found on a bony prominence (Option C).
Which of the following are external factors that subject the skin to injury? A. Emaciation and infections B. Allergens and radiation C. Radiation and emaciation D. Allergens and infection
Correct answer B: Allergens and radiation are external factors that subject the skin to injury. Emaciation (included in Options A and C) and infection (included in Options A and D) are internal factors.
What term describes the softening of tissue by wetting or soaking? A. Eschar B. Maceration C. Sloughing D. Angiogenesis
Correct answer B: Maceration is the softening of tissue by wetting or soaking. Eschar (Option A) is thick, leathery, necrotic, devitalized tissue. Sloughing (Option C) is the separation of necrotic tissue from viable tissue. Angiogenesis (Option D)is the formation of new granulation vessels.
A patient, age 54, is admitted with a diagnosis of venous ulceration unresponsive to treatment. Which of the following is the nurse most likely to find during an assessment of a patient with venous ulceration? A. Gangrene B. Heavy exudate C. Deep wound bed D. Pale wound bed
Correct answer B: Moderate to heavy exudate is one characteristic of a venous ulcer. Other characteristics include irregular wound margins, superficial wound bed, and ruddy, granular tissue. (Options A, C, and D) are incorrect because they're characteristics of arterial ulcers.
The nurse is providing care for a patient who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate when caring for a patient with a wet-to-dry dressing? A. The wound should remain from the dressing. B. The wet-to-dry dressing should be tightly packed into the wound. C. The dressing should be allowed to dry before it's removed. D. A plastic sheet-type dressing should cover the wet dressing.
Correct answer C: A wet-to-dry dressing should be allowed to dry and adhere to the wound before being removed. The goal is to debride the wound as the dressing is removed. (Option A) is incorrect because the wet-to-dry dressing isn't applied to keep a wound moist; a moist saline dressing is applied to keep a wound moist. (Option B) is incorrect because tightly packing a wound damages the tissues. (Option D) is incorrect because a wet-to-dry dressing should be covered with a dry gauze dressing, not a plastic sheet-type dressing.
Which substance enables the transport of oxygen during wound healing? A. Zinc B. Vitamin B6 C. Folate D. Vitamin C
Correct answer C: Folate enables the transport of oxygen during wound healing. Zinc (Option A) enables protein synthesis and tissue repair. Vitamin B6 (Option B) decreases collagen and protein synthesis, and vitamin C (Option D) is needed for collagen synthesis.
A patient with an arterial ulcer over the left lateral malleolus complains of pain at the ulcer site. The nurse caring for this patient understands that the pain is caused most commonly by which of the following? A. Infection B. Exudate C. Ischemia D. Edema
Correct answer C: Severe pain at an arterial ulcer site typically results from ischemia caused by reduced arterial blood flow. (Option A) is incorrect because infection is a complication of arterial ulceration that may not occur in all patients with arterial ulceration. (Option B) is incorrect because arterial ulcers have minimal exudate. (Option D) is incorrect because edema isn't present with arterial ulcers.
The nurse is assessing the laboratory values of a patient with an abdominal wound healing by secondary intention. Which of the following laboratory values indicates that the patient is receiving adequate nutrition? A. Serum albumin level of 2.5g/dL B. Prealbumin level of 12mg/dL C. Transferrin level of 190mg/dL D. Total lymphocyte count of 1,900 uL
Correct answer D: A total lymphocyte count greater than 1,800 uL indicates adequate nutrition. (Options A, B, and C) are incorrect because these laboratory values indicate poor nutrition.
