Fundamentals Exam 2- Skin Integrity Practice Questions
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? A)"Do you experience incontinence?" B)"How many meals a day do you eat?" C)"Do you use any lotions on your skin?" D)"Have you had any recent illnesses?"
A) "Do you experience incontinence?" The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? A)"Your wound will heal slowly as granulation tissue forms and fills the wound." B)"Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." C)"If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." D)"As soon as the infection clears, your surgeon will staple the wound closed."
A) "Your wound will heal slowly as granulation tissue forms and fills the wound." This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? A)As a stage I pressure injury B)As a stage II pressure injury C)As a stage III pressure injury D)As a stage IV pressure injury
A) As a stage I pressure injury Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? A)Discontinue the therapy and assess the client. B)Notify the health care provider of the findings. C)Document the findings in the client's medical record. D)Gently rub and massage the area to warm it up.
A) Discontinue the therapy and assess the client. The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.
What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen? A)Impaired Skin Integrity related to open wound B)Pain related to wound sustained by knife C)Knowledge Deficit regarding wound care related to laceration D)Risk for Infection related to wound
A) Impaired Skin Integrity related to open wound Impaired skin integrity best describes the minor laceration. While the other diagnoses, Pain, Knowledge Deficit, and Risk for Infection, are all possible as a result of the laceration, there is no indication in the scenario that they are the case.
A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown? A)Implement a 2-hour repositioning schedule B)Perform passive range-of-motion exercises C)Massage skin surfaces daily, especially areas under pressure and bony prominences D)Frequently orient client to place and situation
A) Implement a 2-hour repositioning schedule The nurse must regularly turn and reposition the client who is immobile to prevent ischemia and consequent skin breakdown. Other skin integrity interventions include monitoring skin for changes, monitor client's continence status and prevent or minimize exposure to urine and feces, evaluate need for positioning devices and specialty mattresses, nutritional status assessment, and individualize skin care plan. Range-of-motion exercises are good to combat problems related to immobility. Frequent orientation is helpful for clients with dementia. Massage may promote circulation, but it is less important than turning the client on a scheduled basis, and massaging areas over bony prominences could harm the skin's integrity.
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A)a surgical incision with sutured approximated edges B)a large wound with considerable tissue loss allowed to heal naturally C)a wound left open for several days to allow edema to subside D)a wound healing naturally that becomes infected.
A) a surgical incision with sutured approximated edges Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.
A client's risk for the development of a pressure injury is most likely due to which lab result? A)albumin 2.5 mg/dL B)glucose 110 mg/dL C)hemoglobin A1C 7% D)sodium 135 mEq/L
A) albumin 2.5 mg/dL An albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury. A hemoglobin A1C level greater than 8% puts the client at risk for the development of pressure injuries due to a prolonged high glucose level. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not put the client at risk for the development of a pressure injuries.
The nurse would recognize which client as being particularly susceptible to impaired wound healing? A)an obese woman with a history of type 1 diabetes B)a client whose breast reconstruction surgery required numerous incisions C)a man with a sedentary lifestyle and a long history of cigarette smoking D)A client who is NPO (nothing by mouth) following bowel surgery
A) an obese woman with a history of type 1 diabetes Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.
A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected? A)full-thickness skin loss B)skin pallor C)blister formation D)eschar formation
A) full-thickness skin loss A stage IV pressure injury is characterized by the extensive destruction associated with full-thickness skin loss. At stage II, the skin breaks open, wears away, or forms an ulcer or blister, which is usually tender and painful. Slough or eschar may be present on some parts of the wound bed in stage IV but not always. Skin pallor occurs in stage I.
The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding? A)nonblanchable redness B)a shallow open injury C)visible subcutaneous fat D)exposed bone with eschar
A) nonblanchable redness A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. A stage II pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer. A stage III pressure injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. A stage IV pressure injury involves full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often includes undermining and tunneling.
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? A)preventing the client from sliding in bed B)lubricating the area with skin oil C)improving the client's hydration D)pulling the client up from under the arms
A) preventing the client from sliding in bed Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue.
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? A) removing dead or infected tissue to promote wound healing B) stimulating the wound bed to promote the growth of granulation tissue C) removing purulent drainage from the wound bed in order to accurately assess it D) removing excess drainage and wet tissue to prevent maceration of surrounding skin
A) removing dead or infected tissue to promote wound healing Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.
The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? A)Use an aquathermia pad during the treatment to create heat and circulate the water. B)Administer analgesics 30 minutes prior to the treatment to act on pain receptors. C)Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. D)Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles.
B) Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Warm soaks and dressing changes can be painful for clients with abscesses. Often, nurses will premedicate with pain medications, often narcotics, 20 to 30 minutes prior to make the treatments more comfortable for clients. Increasing client comfort can increase effectiveness by allowing the nurse time to adequately perform the treatment, assess the wound, and apply the new dressing. Aquathermia pads are used to promote wound healing, but they are not used simultaneously with water therapies. Dangling the legs and ambulating will not increase comfort.
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? A)Glascow scale B)Braden scale C)FLACC scale D)Morse scale
B) Braden scale The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glascow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls.
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? A)Pasta salad B)Fish C)Banana D)Green beans
B) Fish To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? A)Stage I B)Stage II C)Stage III D)Stage IV
B) Stage II •A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.
While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound? A)stage I pressure injury B)stage II pressure injury C)stage III pressure injury D)stage IV pressure injury
B) stage II pressure injury Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? A)Avulsion B)Abrasion C)Incision D)Laceration
C) Incision An incision is a clean separation of skin and tissue with smooth, even edges. Therefore the nurse documents the finding as an incision. In an avulsion, large areas of skin and underlying tissue have been stripped away. An abrasion involves the stripping of the surface layers of skin. A laceration is a separation of skin and tissue with torn, irregular edges. Therefore the nurse does not document the finding as an avulsion, abrasion, or laceration.
When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? Contact the surgeon for debridement. B) Using sterile technique, debride the wound. C) Off-load pressure from the heel. D) Place an antiembolism stocking on the client's leg.
C) Off-load pressure from the heel. The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. The surgeon does not need to be consulted for a debridement. Utilizing an antiembolism stocking on the client will not impact the status of the heel wound.
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? A)Primary intention B)Maturation C)Secondary intention D)Tertiary intention
C) secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.
A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as: A)Serous B)Sanguineous C)Serosanguineous D)Purulent
C) serosanguineous The nurse should document the drainage as serosanguineous, which is pale pink-yellow, thin, and contains plasma and red cells. Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.
Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A)taking medications as prescribed B)proper intake of food and fluids C)thorough hand hygiene D)adequate sleep and rest
C) thorough hand hygiene The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections. Proper intake of fluids and fiber as well as adequate sleep and rest are general guidelines to promote health. Taking medications especially antibiotics are important if an infection occurs.
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? A)"This is normal tissue." B)"That is old clotted blood underneath the wound" C)"That is called undermining, a type of tissue erosion." D)"That is necrotic tissue, which must be removed to promote healing."
D) "That is necrotic tissue, which must be removed to promote healing." Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.
The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? A)Determine the extent of wound undermining. B)Measure length, width, and depth of the wound. C)Massage the healthy tissue surrounding the wound. D)Document the color, odor, amount, and type of wound drainage.
D) Document the color, odor, amount, and type of wound drainage. After completing a dressing change and retuning the client to a comfortable position, it is important to document color, odor, amount, and the type of wound drainage. Early documentation helps to assure the most accurate information can be recorded. Determining the extent of wound undermining and measuring length, width, and depth of the wound should be performed during the dressing change, while the wound is still exposed. The healthy tissue surrounding the wound should never be massaged because it could cause further breakdown of healthy tissue.
The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication? A)Fistula B)Dehiscence C)Hemorrhage D)Evisceration
D) Evisceration Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.
What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A)Self-Care Deficit B)Risk for Imbalanced Nutrition C)Anxiety D)Risk for Infection
D) Risk for Infection Clients who are taking corticosteroid medications are at high risk for delayed healing and wound complications such as infections. Corticosteroids decrease the inflammatory process, which may in turn delay healing. Self-Care Deficit may occur with a client who has challenges with physical ability. Imbalanced Nutrition would occur with a client who cannot take in adequate nutrition. Anxiety can occur with clients who have psychological issues.
A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk? A) a client 45 years of age who has paraplegia B) a client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history C) a client 75 years of age who uses a cane and has dementia D) a client 68 years of age who is bedrest related to severe head trauma
D) a client who is 68 and on bed rest
When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk? A)Friction B)necrosis of tissue C)Ischemia D)shearing force
D) shearing force A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? A)stage I B)stage II C)stage III D)stage IV
D) stage IV Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.
