Wound Care - WND580 Quiz Review
Mrs. Anderson has dependent rubor and elevation pallor of her right lower extremity. The systollic pressure in her R arm is 170 mmhg: L arm is 165 mmHg; R dorsal pedis systolic pressure was 100 mmHg and the posterior tibial pressure was 95 mmHg . What is Mrs. Anderson's ABI for the RLE?
0.59
Traditional negative pressure wound therapy is an appropriate option for what type of wound?
A dehisced abdominal incision with copious exudate and mild periwound erythema.
You were called to the cancer center to evaluate a patient receiving daily radiation to his R neck region. You note primarily dry desquamation with small patches of weeping skin, redness and edema. What modality would not be appropriate for this patient?
A moisture retentive adhesive dressing
What is the assessment most indicative of an arterial ulcer?
An ABI of 0.7
Patients undergoing myocutaneous flap closure of a pressure injury are best managed in the initial postoperative period on what type of support surface?
An air fluidized bed with non-shear surface
The nurse assessing the pain of a patient with chronic leg ulcers documents a moderately severe pain level of seven. What intervention wound not be an appropriate adjunct to his scheduled pain medication?
Application of sliver sulfadiazine to reduce bioburden
Your wound assessment reveals a full thickness ulcer, with scant amount of serosanguinous drainage. You note that the woundbase is pale pink and there is a tunnel at 3 o'clock. The wound measurements are unchanged in the last 2 weeks. The patient denies pain with palpation, but you note mild periwound erythema. what would be your best response in developing the plan of care for the patient?
Apply an antimicrobial hydrofiber rope into the tunnel
A 34-year old female is admitted for management of pain and palliative wound care for metastatic breast cancer. During her physical exam, the wound in the left breast is a fungating mass sized at 12cmx10cm and various heights with slough and scant drainage. What physiologic wound care would you recommend?
Apply hydrogel sheets to the left breast to gently debride and decrease pain
Mr. Benn's venous ulcers have now resolved completely. You have fitted his with proper below the knee compression stockings. Your discharge instructions include which of the following?
Apply stocking upon rising in the morning.
As you examine a patient's lower extremity you observe a thin leg with dry skin and very little hair; the ABI is 0.5. From this data, what condition would you assess to be present?
Arterial insufficiancy
which of the following debridement techniques is within the scope of practice of the WOC nurse and expedites the removal of a non-infective eschar covering a pressure injury?
Autolytic debridement
Mr. Simpson has a BMI > 40 and is admitted for R sided hemiplegia due to a stroke. Considering pressure redistribution needs for this bariatric patient what would be the most appropriate in meeting his unique needs?
Bariatric bed with therapeutic mattress and microclimate control
What is the primary reason for taking the time to perform a comprehensive assessment to identify protein energy malnutrition as opposed to ordering a simple blood draw to formulate a diagnosis?
Blood tests do not provide a stand alone assessment.
You are providing some patient education for a patient at risk for a neuropathic foot ulcer in obtaining proper footwear, what is not an important factor in selecting proper footwear?
Both feet should be measured and shoes sized to the smaller foot.
What would be most appropriate as a primary dressing for an exudative pressure injury with a depth of 4.5cm?
Calcium alginate
What is Mrs. Lang's foot deformity called when there is a rocker bottom appearance to her foot?
Charcot's joint
A 98 year old has a pressure injury that is not healing. She has a low zinc level. how does the low zinc level affect her wound healing.
Collagen synthesis will be delayed.
Mr. Lee was found lying at home on the floor. Upon admission, he has an intact, nonblanchable, persistent purple discoloration over the coccyx. Which describes the classification of his pressure injury?
Deep Tissue Injury
Mr. Best has been diagnosed with lower extremity arterial disease. What risk factor for arterial disease may have played the greatest role in atherosclerosis development?
Diabetes mellitus
The recombinant PDGF (platelet derived growth factor), Regranex is specifically indicated for which of the following wounds?
Diabetic plantar ulcers
Of the following wound care strategies, which demonstrates knowledge of physiologic wound care?
Dressing change orders at intervals recommended by the manufacturer (usually every 3-4 days) or if leaking.
What diagnostic test is considered the Gold Standard for diagnosing LEVD
Duplex Ultrasound
Upon assessing Mrs. Jones sacral pressure injury, you note a lack of reduction of size in a clean granulating wound for the last 4 weeks thus suggested the used of electrical stimulation because of the following positive effects?
Enhance perfusion and migration of cells critical for healing
The phenomenon of contact inhibition is associated with
Epithelial migration as a wound resurfaces.
Which statement accurately describes the characteristic and implication of necrotic tissue in a wound bed?
Eschar usually is black, brown, or gray and associated with deeper tissue damage. It is usually firmly attached to the wound base.
A 32 year old paitent has several linear, hallowed out lesions with the loss of epidermis on his left lower leg. In his visit documentation, you describe these lesions as a
Excoriation
What cells located in the dermis produce collagen (dermal building blocks) and elastin (tensile strength)?
Fibroblasts
What dressing is best for the moderately exudative venous ulcer?
Foam Dressing
What is indicative of a wound infection?
Friable red wound bed, increase in exudate production, periwound erythema and odor.
What is not considered a primary etiologic factor for pressure injuries?
Friction
which of the following statements concernign the management of a mixed venous/arterial ulcer with an ABI of 0.75 is TRUE
Graduated compression can e provided at a modified level of support
When changing a wound dressing over a full thickness wound, you notice the wound bed is shiny, moist, red and has a cobblestone appearance. What terminology would you use to document this observation?
Granulation is present
Mr. Greenjeans appears anxious and reports previous experiences of pain during NPWT dressing changes. What interventions may reduce the patient anxiety and pain during NPWT dressing changes?
Have the patient watch a comedy show on TV, use an adhesive remover to loosen drape, soak the black foam with NS for 5 minutes then remove
As a specialist working in wound care, it is important to involve the patient in determining the goal for the wound. Some therapies are so time-consuming and expensive that patients may not continues to be adherent to protocols. What is an example of a goal for a wound?
Healing, maintenance (delayed healing) and comfort
An elderly female developed a dehisced wound following abdominal surgery for a bowel obstruction. What condition best explains what placed her at risk for developing a wound dehiscence?
History of radiation in the surgical field
Which of the following dressing would be most appropriate for the patient with a full thickness pressure injury with significant undermining and a dry wound bed?
Hydorgel impregnated gauze
The wound care nurse is following the TIME concept to promote wound healing. Which statement accurately describes this concept based on the Tissue management step of the framework?
Hypergranulation tissue slows wound healing by preventing epithelialization.
Which of the following is a benefit of moist wound healing?
Increased production of collagen
Mr. Brown has a mild to moderate urinary incontinence and limited mobility. What will most likely occur due to the effects of prolonged moisture on his peri-genital skin?
Increased risk of mechanical injury
The wound care nurse is monitoring the cleansing process of a necrotic wound. What technique is recommended?
Irrigate the wound with a 4 to 15 psi force
which of the following is a benefit of moist wound healing?
It promotes autolysis
The wound care nurse is investigating why modalities and treatments used in the management of wounds are less effective with spinal cord-injured patients. What is one reason to consider?
Lack of spasticity management and AD(autonomic dysreflexia)trigger identification
A heel ulcer with a non-infected stable eschar is BEST managed by:
Leave open to air
A patient in the outpatient wound clinic has a venous ulcer and with palpation, the skin around the ulcer feels firm and woody or hardened. This describes what condition?
Lipdermatosclerosis
You are observing the limbs of a new patient and note that one limb has brawny non-pitting edema from the toes to groin and positive Stemmer sign while the other is without edema and n distortion in the leg shape. What type of disorder is this patient most likely suffering from?
Lymphedema
The preoperative preparation for the surgical repair of an extensive wound should include the following intervention to reduce or control host factors?
Maintain blood glucose of 130 mg/dl or less (tight glycemic control)
The preoperative preparation for the surgical repair of an extensive wound should include what intervention to reduce or control host factors?
Maintain blood glucose of 130 or less
47% of all pressure injuries occur over the ischial tuberosities and sacrum. What primary prevention intervention would the nurse institute to address the ischial tuberosities based on this statistic
Maintain the wheelchair seat cushion in proper working order
The wound nurse is providing discharge education to a patient who suffered a deep partial thickness burn to their lower extremity. What intervention would be most appropriate in the plan of care?
Moisturizers and OTC antihistamines
You are aware that age itself is not a risk factor for failure to heal wounds. Problems in wound healing for the elderly are most likely associated with:
Multiple co-morbidities
An ambulatory patient with insulin dependent diabetes has an ulcer located on the plantar surface of the left foot over the third metatarsal head. The ulcer is 1 cm in diameter, with a dry red surface. The patient denies any pain in the ulcer. What type of wound does this most likely represent?
Neuropathic ulcer
Arterial disease, hypotension, vasopressors and severe anemia can be deleterious to wound healing because they decrease the amount of:
Oxygen in the tissue
Mr Carter is in ICU following coronary artery bypass graft surgery. He communicates that he is having significant pain. The incision on his upper right thigh is approximated and intact and covered with a transparent dressing: a slight redness is noted around the incision. What assessment place him at risk for impaired oxygen perfusion to tissues surrounding the thigh wound?
Pain
You have a patient in acute care who has multiple risk factors for skin breakdown. What is true regarding frequency of skin assessment?
Patients at risk for skin break down should have at least a daily skin inspection
You have a patient in acute care admitted for an exacerbation in the congestive heart failure. Which of the following statements is true regarding frequency of skin inspection?
Patients should have at least daily of once a shift skin inspections.
What cell plays a central role in initiating the wound repair process?
Platelets
You are called to the ICU to evaluate a critically ill patient who is hemodynamically unstable. What is considered and evidence based recommendation for this population?
Position on the right side and use pillow or wedges to create small lateral shifts of 15 degrees
Your have a patient with an ischial tuberosity pressure injury that is covered with 100% necrotic tissue. Prior to performing conservative sharp debridement, what factor is the least of importance in the ability to perform conservative sharp debridement?
Presence of loose, avascular tissue in the wound
Urinary and fecal incontinence is considered a risk factor for pressure injury development because of what factors?
Promotion of maceration and friction
As the wound care nurse specialist, you are teaching your skin care team about the importance of maintaining a physiologic wound environment. One of your nurses asks the question, "what is a physiologic environment for a wound?" The best response would be conditions established in the wound that:
Provide the wound with adequate moisture, pH regulation, control of temperature and bioburden
Hyperbaric oxygen treatments(HBOT) are indicated for what conditions?
Radiation induced necrotic wounds
A colleague is talking with you in the elevator about your wound care protocols and practice. The question raised is: what type of evidences dot you have to validate that you practice is evidence based?
Randomized controlled studies, guidelines for practice from reputable wound care societies
Which treatment would be most appropriate for the management of a partial thickness wound with a fully approximated epidermal flap?
Re-approximate edges and apply a non-adherent dressing
Your are called to a care conference to help the skin care team determine a plan of care to promote bariatric skin integrity. What is not a risk factor for alteration in skin integrity for those who suffer obesity?
Reduced bacterial load on the skin
The new patient admitted to the LTAC(Long Term Acute Care) has a stage 3 pressure injury with 100% granulation tissue and moderate amount of exudate. The wound edge is well defined with a rolled edge from 12 to 5 o'clock. The most appropriate intervention you select for the wound is the following
Referral to open the edges
the care plan for the patient with pressure risk assessment score (Braden Scale) of 9 and on a therapeutic support surface should always include:
Reposition the patient every 2-4 hour depending on tissue tolerance
An intubated pt. with HOB elevated to 45 degrees. Has a stage 3 pressure ulcer on her coccyx with undermining. Which of the following risk factors is most responsible for undermining in the pressure injuries?
Shear from having the HOB elevated to 45 Degrees.
What dressing in most appropriate to use in a pressure injury with a granulation tissue filled wound bed measuring 3cmx5cmx2.5cm with undermining that extends 4 cm from 6-9 o'clock? The wound has become increasingly exudative in the past 3 weeks.
Silver impregnated alginate rope
90 Year old female in the nursing home has a partial thickness wound with a fully approximated epidermal flap on her left forearm. What type of skin damage is present
Skin tear, type 1
A patient with paraplegia is in the wound clinic to have a new seating surface re-evaluated. You notice a serous fluid filled blister on the left heel which you document as a pressure injury in what stage?
Stage 2
What qualifies a patient with a low braden mobility subscale score of 2 and moisture subscale of 1 for a low air loss redistribution support surface(bed)?
Stage 3 sacral pressure injury
You have a patient with COPD who needs the HOB elevated most of the time, diaphoretic dues to fevers, and a braden score of 9. What would be the best pressure redistribution surface?
Surface with a low shear cover and low air loss feature
You are evaluating a palliative care patient with a lower extremity arterial ulcer. what is the primary goal and treatment focus in developing a plan of care?
Symptom control and prevention of pressure ulcers.
Mrs. James has an eschar covered heel ulcer and you decide that the best approach to management is not to debride but to keep the eschar covered dry and intact, the rationale for your decision is that the
TcPo2 (transcutaneous oxygen) is 15mmHg
What is a statement about contact casting?
The contact cast redistributes the weight of the diabetic foot
A swab culture of the surface of the wound can misdiagnose a wound infection because:
The surface organisms may not represent the organisms invading the wound tissue.
What is a statement about inelastic compression bandages?
They are only effective in the ambulatory patient.
Gauze is a dressing material with a high moisture vapor transmission rate(MVTR). When wounding of the skin occurs the transepidermal water loss(TEWL) rate of the skin goes up. When these two conditions exist, what is happening in the wound?
Tissue dehydrates because the TEWL is increased and a dressing material is in use that allows for additional dehydration. This situation frequently results in cell death.
which of the following causes of massive tissue loss is most commonly associated with a severe drug reaction?
Toxic Epidermal Necrolysis (TEN)
Ultrasonic mist aids in debridement of necrotic tissue and reduces bioburden of wounds using:
a saline mist
Mrs. Jones has an ulcer located on the dorsal surface of the third toe on the left foot. The ulcer is 1 cm in diameter, with a dry pale pink wound bed. She reports significant pain in the ulcer and denies any history of diabetes. What is the most likely cause of this ulcer?
arterial insufficiency
This wound will heal with a scar formation.
full thickness wound
Acute vs chronic wound characteristics are:
have different types of cellular activity, different levels of proteases
Which area of the body is the most difficult to offload using a pressure redistribution surface?
heel
A patient has an acute full-thickness wound due to trauma. What order of healing would occur with this wound?
hemostasis, inflammation, proliferation and maturation
What dressing would be most appropriate for a shallow, clean, granulating wound that measures 2cmx1.5cm and has minimal exudate?
hydrocolloid dressing
As wound healing progresses, collagen deposition and remodeling occur and has which of the following effects?
increased tensile strength
When the skin around a wound develops a whitish appearance, it can be described as?
maceration.
A full thickness wound is considered difficult to heal (refractory or recalcitrant) if:
no improvement in 2-4 weeks despite appropriate treatment
Lymphedema is the accumulation of
protein rich fluid in the soft tissue
The nursing staff calls you because a patient suffered an extravasation of Vancomycin at a peripheral IV site, you immediate instructions are to
recommend topical wound therapy once residual drug is aspirated
The 3 principles of wound care provide a useful format for prioritizing approaches in wound care. They are:
reduce/eliminate the cause of the wound, support the host and maintain a physiologic environment.
Venous dermatitis
results in erythema, crusting, scaling skin of the leg
As you setup a skin care program, you identify the elderly to be at risk for skin tears due to the effects of aging on the:
rete ridges
Your are called to the neonatal intensive care unit regarding appropriate products to use on the skin of neonates. What product would be considered safe to use on the neonates skin?
silicone
One of the reasons scab formation and necrotic tissue are generally considered undesirable in the wound is because they:
slow the process of epithelialization
A partial thickness wound is considered difficult to heal(refractory wound) if:
there has been no improvement in 1-2 weeks despite appropriate treatment
A patient has pyoderma gangrenosum with a LE ucleration. It is acutely painful and typically breaks down to form a progressively larger ulceration with a bright red "halo" on the ulcer border. It also typically has a purple (violaceous) border and may have underminning at the wound edges, inflamed, necrotic base, boggy tissue, purulent drainage. What is the treatment?
treat the underlying disease
Intermittent claudication leg pain is characterized as pain that occurs
with activity and is relieved by rest
Traditional negative pressure wound therapy is indicated for:
wounds with 80% granulation tissue in the wound bed
