Wound Care #2
After what period of time should you conduct a comprehensive reassessment of the patient, wound, and plan of care if signs of healing are not present? 1 week 2 weeks 3 weeks 4 weeks
2 weeks
Which of the following patients is MOST likely to have sickle cell ulcerations. 17-year-old Caucasian patient 23-year-old African-American patient 45-year-old Asian patient 82-year-old Caucasian patient
23-year-old African-American patient
What is the normal value for white blood cells? 13.2-16.6 g/dL 135,000-317,000/μL 3,400-9,600/μL 4.32-5.72 million/μL
3,400-9,600/μL
How long does it take for blanchable erythema (tissue hyperemia) to develop? 1200 minutes 30 minutes 60 minutes 90 minutes
30 minutes
What is the recommended caloric intake for wound healing? 15-20 kcal/kg 20-25 kcal/kg 25-30 kcal/kg 30-35 kcal/kg
30-35 kcal/kg
At what point in the care of a wound would it be appropriate to consider the use of a cellular and tissue-based product (CTP) if the wound has failed to respond to conservative measures? 1-2 weeks 2-3 weeks 4-6 weeks 8-12 weeks
4-6 weeks
What is the pH of the skin? 3.0-4.8 4.0-6.8 5.2-7.0 6.8-8.0
4.0-6.8
What is the longest time between dressing changes that is appropriate for diabetic foot ulcers? 10 days 3 days 5 days 7 days
5 days
What is the recommended preprandial blood glucose level according to the American Diabetes Association? 100-160 mg/dL 50-100 mg/dL 70-110 mg/dL 80-130 mg/dL
80-130 mg/dL
A patient receiving palliative care suddenly develops a dark pear-shaped ulcer on the sacrum with irregular borders that progressed rapidly in size. These characteristics suggest that the patient has: A Kennedy terminal ulcer A Marjolin ulcer Calciphylaxis Pyoderma gangrenosum
A Kennedy terminal ulcer
Which of the following patients would an air-fluidized bed be MOST appropriate for? A patient at risk for pressure injuries but without an existing injury A patient with a Stage 1 pressure injury to the left heel A patient with a Stage 2 pressure injury to the medial malleolus A patient with a Stage 4 pressure injury to the right trochanter and sacrum
A patient with a Stage 4 pressure injury to the right trochanter and sacrum
To assess pain with non-verbal or patients with cognitive impairment, it is recommended to use: A categorical scale A multidimensional scale A numeric scale A visual analog scale
A visual analog scale
When sweat and sebum mix on the skin they produce: A dark skin pigmentation A Vitamin D precursor An acid mantle Collagen and elastin
An acid mantle
What is the appropriate technique to handle sagging wound edges during measurement? Apply equal amounts of tension to both edges of the wound. Measure how far the edges sag. Stretch the skin to a maximum degree of tension. Use multiple positions for measurements.
Apply equal amounts of tension to both edges of the wound.
Which nutrient stimulates insulin secretion, promotes transportation of amino acids into tissue cells, and supports formation of protein in cells? Arginine Carbohydrates Fat Glutamine
Arginine
Your patient has an ulcer to the lateral malleolus in which the surrounding skin appears hairless and is cool to touch. What is the MOST likely etiology of this ulcer? Arterial insufficiency Diabetes Pressure and shear Venous insufficiency
Arterial insufficiency
At what point in care delivery are you required to provide the patient the Notice of Privacy Practices? After their first visit At their first visit Before their first visit Upon referral
At their first visit
All of the following are processes involved in venous hypertension EXCEPT: Atherosclerosis of the arteries Damaged valves Loss of fluids into surrounding tissues Poor calf muscle pump function
Atherosclerosis of the arteries
Your patient has a laceration closed by tissue adhesive. What patient education should you provide? Apply a moisturizing cream to the area. Avoid prolonged soaking or swimming. Remove the film after one week. Take a shower within 24 hours.
Avoid prolonged soaking or swimming.
Your patient presents with patchy, small round erythematous papules and pustules in the groin and gluteal folds with a cheesy white exudate. The patient complains of itching and burning. What is the MOST likely etiology of this skin condition? Candida Erythrasma Incontinence-associated dermatitis Intertriginous dermatitis
Candida
What dressing would be MOST appropriate for a low-output fistula with odorous effluent? Alginate Charcoal Dry gauze Hydrocolloid
Charcoal
What is lesion distribution? Clinical arrangement Form or structure Shape or outline Type
Clinical arrangement
What does a fibroblast produce? Collagen and elastin Desmosomes Melanin and melanocytes Red blood cells
Collagen and elastin
What action should occur before debriding a pressure injury on the lower extremity? Conduct a vascular assessment including ankle brachial index. Consult with a surgeon for evaluation of the necrotic tissue. Determine whether a biofilm is present in the wound. Identify whether the eschar is stable or unstable.
Conduct a vascular assessment including ankle brachial index.
If a patient receives excess zinc supplementation, what other nutrients will the zinc interfere with? Carbohydrates and fat Copper and iron Fat and protein Vitamins B and C
Copper and iron
Which of the following factors can help reduce the risk a medical device will cause a pressure injury? Correct size and shape Harder, less flexible device High-friction device interface Larger skin-device interface
Correct size and shape
The removal of dead, devitalized, or contaminated tissue or foreign material in a wound is called: Cauterization Contraction Debridement Granulation
Debridement
What layer of tissue does a deep partial-thickness burn extend into? Deep dermal layer Epidermal layer Subcutaneous layer Superficial dermal layer
Deep dermal layer
Your patient has a painless wound on their foot with a callused margin. What is the MOST likely etiology of this ulcer? Arterial insufficiency Diabetes Pressure and shear Venous insufficiency
Diabetes
An old traumatic wound with retained devitalized tissue would be classified as a: Clean wound Clean-contaminated wound Contaminated wound Dirty-infected wound
Dirty-infected wound
Your patient started radiation treatment three weeks ago. The affected skin is dry, itchy, peeling, and hyperpigmented. What does this describe? Delayed radiation reaction Dry desquamation Moist desquamation Radiation recall
Dry desquamation
Which of the following is an indicator of poor nutritional habits? Clear liquid diet for 48 hours Eating more than 50-75% of food served Eating primarily carbohydrates Refusal of breakfast in the morning
Eating primarily carbohydrates
How often are total contact casts usually changed? Every 1-2 weeks Every 2-3 days Every 2-3 weeks Every 5-7 days
Every 1-2 weeks
Once a clot has formed, what process is activated? Angiogenesis Contraction Fibrinolysis Inflammation
Fibrinolysis
An abnormal passage between two or more structures or spaces is called a: Abscess Fistula Furuncle Undermine
Fistula
All of the following are good practices for effective communication EXCEPT: Allow time for the person to absorb the message. Avoid making negative remarks about a suggestion. Formulate your response as the person is talking. Pay attention to non-verbal cues.
Formulate your response as the person is talking.
Upon assessment of a wound, it is observed to have a nodular cauliflower shaped appearance. This characteristic suggests: Fungating malignant wound Pemphigus Pyoderma gangrenosum Sickle cell ulcer
Fungating malignant wound
Your patient has had a depletion in lean body mass (LBM) of 8%. How does this affect the relationship between wound healing and restoration of LBM? Healing of the wound takes priority over available protein substrate. Protein intake is used for neither wound healing nor restoration of LBM Protein is used for both wound healing and restoration of LBM. Restoration of LBM takes priority over protein intake.
Healing of the wound takes priority over available protein substrate.
What phase of wound healing has a primary function of coagulation? Hemostasis Inflammatory Maturation Proliferative
Hemostasis
What is the MOST appropriate topical treatment if the goal of wound care is to add moisture to a dry wound? Alginate Hydrogel Silicone dressing Transparent film
Hydrogel
What would be the MOST appropriate topical treatment for a painful wound that has scant to no exudate? Alginate dressing Hydrocolloid dressing Hydrogel with lidocaine Transparent film
Hydrogel with lidocaine
Which of the following is a factor that increases wound healing in neonates and children? Decreased body surface/weight ratio Increased number of fibroblasts Slow production of collagen and elastin Slower formulation of granulation tissue
Increased number of fibroblasts
The presence of wound infection keeps the wound in what phase of healing? Hemostasis Inflammatory Maturation Proliferative
Inflammatory
What phase of wound healing has a primary function of debris removal? Hemostasis Inflammatory Maturation Proliferative
Inflammatory
A process of communication between the patient and healthcare provider that leads to agreement or permission for care, treatment, or services is called: Billing agreement Informed consent Patient education Privacy notice
Informed consent
How do the wound margins of pyoderma gangrenosum typically present? Irregular, raised, and violet or blue Jagged, raised, and gray Oblong, raised, and hyperkeratotic Round, even, and red
Irregular, raised, and violet or blue
What fat-soluble vitamin is required for coagulation? A D E K
K
The application of a porous, mesh-like covering over a wound after the application of maggots serves to: Eliminate oxygen to the maggots. Hide the maggots from the patient's view. Keep the maggots from migrating away. Kill the maggots after they finish feeding.
Keep the maggots from migrating away.
What factor associated with diabetes increases the risk for ulceration by seven-fold? Deformities to the foot Impaired arterial perfusion Loss of protective sensation Uncontrolled blood glucose levels
Loss of protective sensation
In which of the following diabetic foot ulcers would the use of hydrocolloids be acceptable? Large amount of exudate, signs of infection, no ischemia Low exudate, free of infection, and no ischemia Presence of ischemia, low exudate, and free of infection Signs of infection, moderate exudate, and no ischemia
Low exudate, free of infection, and no ischemia
What skin complication of lymphedema is associated with lumpy, firm raised projections on the skin with a cobblestone appearance? Lymphangiosarcoma Lymphangitis Lymphatic papillomatosis Lymphorrhea
Lymphatic papillomatosis
What cell recognizes and produces antibodies? Lymphocyte Neutrophil Platelet Red blood cell
Lymphocyte
Which of the following cells would you find in the dermis? Keratinocytes Macrophages Melanocytes Merkel cells
Macrophages
During what phase of full-thickness wound healing does the wound remodel and increase tensile strength? Hemostasis Inflammatory Maturation Proliferative
Maturation
Your 85-year-old patient with a wound is on a low sodium, low fat diet and frequently eats less than 50% of food served. What is the FIRST intervention you should consider to improve nutritional status? Ask the physician to start a daily zinc supplement. Discuss with the patient the need for enteral nutrition. Double the portions the patient is receiving. Modify or liberalize dietary restrictions.
Modify or liberalize dietary restrictions.
What two factors can cause a chronic wound to remain in the inflammatory phase? Bleeding and fibrinolysis Epibole and exudate Necrotic tissue and infection Scar tissue and moisture
Necrotic tissue and infection
What white blood cell is the most common type, a major player in the body's defense against bacterial infections, and the first to arrive at a site of infection? Basophil Leukocyte Lymphocyte Neutrophil
Neutrophil
Testing for elevational pallor in the lower extremities assesses for: Occlusive disease Oxygen level Protective sensation Venous insufficiency
Occlusive disease
Hyperbaric oxygen would be MOST appropriate for which of the following conditions? Clean healing pressure injury Dry gangrene Osteomyelitis Venous insufficiency
Osteomyelitis
Which of the following tools is used to determine pressure injury healing? Braden Norton PAINAD PUSH
PUSH
Your primary responsibility when providing wound care is to the: Caregiver Patient Physician Public
Patient
What oral medication may be used in the treatment of venous ulcers? Atorvastatin (Lipitor®) Enalapril (Vasotec®) Glipizide (Glucotrol) Pentoxifylline (Trental®)
Pentoxifylline (Trental®)
What does an ABI value of 0.70 indicate? No peripheral arterial disease Peripheral arterial disease Possible peripheral arterial disease Severe peripheral arterial disease
Peripheral arterial disease
Which member of the interprofessional team provides adjunctive therapy such as ultrasound and electrical stimulation? Dietitian Nurse Physical therapist Speech therapist
Physical therapist
The process of activation and aggregation in the hemostasis phases occurs when what cells encounter collagen from damaged tissue? Cytokines Fibroblasts Neutrophils Platelets
Platelets
How would you characterize the vascularization of adipose tissue? Heavily vascularized Not vascularized Poorly vascularized Well vascularized
Poorly vascularized
Pain that occurs when the leg is elevated and is relieved when in a dependent position is called: Atypical claudication Intermittent claudication Positional pain Resting pain
Positional pain
A patient with mobility issues presents with a full-thickness ulcer to the left lateral malleolus with non-blanchable erythema around the ulcer. The caregiver states the patient always lies on their left side when in bed. What is the MOST likely etiology Arterial insufficiency Diabetes Pressure Venous insufficiency
Pressure
Partial-thickness wound healing occurs through the process of: Granulation Maturation Neoangiogenesis Regeneration
Regeneration
All of the following are good practices for dealing with conflict EXCEPT: Clarify issues surrounding values, purposes, and goals. Find a private setting for confrontation. Resolve a problem when emotions are high. Set aside enough time to weigh all possible solutions.
Resolve a problem when emotions are high.
One example of a valid and reliable nutrition screening tool is: BRADEN CRIES PUSH SNAQ
SNAQ
What type of wound closure would a venous ulcer undergo? Delayed primary intention Primary intention Secondary intention Tertiary intention
Secondary intention
Lesions that appear as if they are meandering or wandering as though following the track of a snake is what type of configuration? Circinate Gyrate Serpiginous Zoster
Serpiginous
Pain scales assess for pain: Quality Radiation Severity Timing
Severity
What is the gold standard for debriding hyperkeratotic skin around a diabetic foot ulcer? Autolytic debridement Biological debridement Enzymatic debridement Sharp debridement
Sharp debridement
What type of compression provides a lower amount of pressure at rest and a higher amount with activity? Antiembolism stockings Long-stretch elastic wraps Long-stretch non-elastic wraps Short-stretch inelastic wraps
Short-stretch inelastic wraps
How would you stage an intact serum-filled blister on the right heel? Deep tissue injury Stage 1 Stage 2 Unstageable
Stage 2
The presence of slough in a pressure injury indicates the LOWEST stage the pressure injury can be is a: Stage 1 Stage 2 Stage 3 Stage 4
Stage 3
Your patient has a deep pressure injury to the right ischium that has granulation tissue present. You do not observe nor can palpate any underlying structures. How would you stage this wound? Stage 2 Stage 3 Stage 4 Unstageable
Stage 3
Your patient has a pressure injury to the bridge of the nose from a CPAP machine. You notice the wound has a very shallow depth with exposed bone. How would you stage the pressure injury? Stage 2 Stage 3 Stage 4 Unstageable
Stage 4
What does the presence of epibole at the wound margins indicate? A healed wound An infected wound Healthy wound margins Stalled epithelialization
Stalled epithelialization
What acronym is used to identify the four major components to wound bed preparation required for healing? BEAM NERD STON TIME
TIME
The collagen produced by fibroblasts in the dermis is responsible for giving the skin: Elastic recoil Insulation Sensation Tensile strength
Tensile strength
Compression creates a higher pressure at what part of the leg? The ankle The calf The knee The thigh
The ankle
All of the following should be included when documenting a wound care procedure EXCEPT: How well the patient tolerated the procedure The cost of the procedure When the procedure was performed Who performed the procedure
The cost of the procedure
When measuring a wound on a location other than the foot using the clock method, what part of the body does 6 o'clock represent? The foot The head The left side The right side
The foot
The presence of non-proliferating microbes in a wound that do not cause clinical problems indicates: A local infection is present. The wound is colonized. The wound is contaminated. Topical antimicrobial treatment is needed.
The wound is contaminated
What is the overall goal of wound bed preparation? To achieve a well-vascularized wound bed with minimal exudate To modify patient factors that impact wound healing To return the wound to the hemostasis phase of wound healing To turn a chronic wound into an acute wound
To achieve a well-vascularized wound bed with minimal exudate
In what direction would you cleanse a linear wound? Bottom to top Circular motions Side to side Top to bottom
Top to bottom
What theory of venous ulceration involves the binding of fibrin to growth factors and other mediators needed for normal tissue maintenance and healing? Fibrin cuff theory Trap hypothesis WBC binding theory WBC trap theory
Trap hypothesis
Your patient has a skin tear in which you are able to approximate the epidermal flap to cover the wound bed. Under the ISTAP Skin Tear Classification, what type of skin tear does this represent? Type 1 Type 2 Type 3 Type 4
Type 1
What stage is a pressure injury to the sacrum that is 100% covered with black eschar? Deep tissue injury Stage 3 Stage 4 Unstageable
Unstageable
Which of the following is an acceptable practice for skin care in patients at risk for pressure injuries? Use a barrier product on skin exposed to moisture. Use alkaline-based skin cleansers. Use hot water during cleansing. Use rough fabrics for cleansing and drying
Use a barrier product on skin exposed to moisture.
A patient is unable to tolerate therapeutic levels of compression. What would be the most appropriate action to take? Use of a tubular sleeve Use of ACE bandages Use of anti-embolism stocking Use of support stockings
Use of a tubular sleeve
Your patient presents with a shallow ulcer with red granulation tissue present on the medial lower leg. What is the MOST likely etiology of this ulcer? Arterial insufficiency Diabetes Pressure and shear Venous insufficiency
Venous insufficiency
What vitamin is a cofactor in collagen formation and fibroblast function? Vitamin A Vitamin B Vitamin C Vitamin D
Vitamin C
You should document the status of the wound at least: Daily Every two weeks Monthly Weekly
Weekly
How often should a risk assessment tool be completed after admission to a long-term care facility? Annually Daily for 7 days Monthly for 3 months Weekly for 4 weeks
Weekly for 4 weeks
Why is closure enhanced when a wound heals by primary intention? Epithelial resurfacing does not need to occur. More tissue has to be formed. The presence of dead space enhances granulation. Wound contraction is fastest across linear wounds.
Wound contraction is fastest across linear wounds.
How would you stage a mucosal membrane pressure injury? Stage 1 Stage 2 Unstageable You would not stage it.
You would not stage it.
