Chapter 35: Skin Integrity and Wound Healing

A client appears sleepy immediately after dinner. What should the nurse do to enhance this client's sleep and rest? 1) Provide a sleep aid. 2) Turn on the television. 3) Encourage the client to walk in the hall. 4) Provide a cup of caffeinated coffee.

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During which developmental stage does a person tend to need the most hours of sleep? 1) Toddler 2) Adolescence 3) Middle adulthood 4) Older adulthood

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What would be the primary focus of interventions for a 6-year-old client who sleepwalks? 1) Maintain patient safety during episodes of somnambulism. 2) Administer and teach about medications to suppress stage III sleep. 3) Encourage the child to verbalize feelings regarding sleep pattern. 4) Provide a quiet environment for nighttime sleep.

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Which factor has the greatest positive effect on sleep quality? 1) Sleeping hours in synchrony with circadian rhythm 2) Sleeping in a quiet environment 3) Spending additional time in stage NIII of the sleep cycle 4) Napping frequently during the day hours

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Which is a pattern of waking behavior that appears during sleep? 1) Parasomnias 2) Dyssomnias 3) Insomnia 4) Hypersomnia

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You are maintaining a client's Penrose wound drain. Which of the following actions should you most expect to take when caring for this type of drain? 1) Advance the drain by pulling it out of the wound a specified distance each day. 2) Compress the device to create suction. 3) Advance the drain by inserting it farther into the wound a specified distance each day. 4) Inspect the sutures holding the drain in place for signs of inflammation.

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SATA. You are caring for an older client who is at high risk for developing pressure ulcers. Which of the following interventions should you take to help prevent pressure ulcers? 1) Conduct a pressure ulcer admission assessment using the Braden scale. 2) Inspect bony prominences daily in good light. 3) Apply moisture barrier creams to perineal skin after each incontinent episode. 4) Bathe the client daily with hot water. 5) Offer a drink of water whenever you reposition the client. 6) Reposition the client at least every 8 hours.

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SATA. You are preparing to use the Braden scale to assess a client's risk for developing pressure ulcers. Which of the following risk factors does this scale evaluate? 1) Sensory perception 2) Mental state 3) Moisture 4) Incontinence 5) Activity 6) Mobility

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SATA. As you are documenting a client's treated pressure ulcer, you are careful to note its precise location. Which of the following are correct rationales for noting the location of the ulcer? 1) The location influences the rate of healing. 2) The location determines whether to pursue healing by primary or secondary intention. 3) The location determines whether to apply sterile or nonsterile dressings to the wound. 4) The location affects the client's ability to move. 5) The location can give you clues to the wound's etiology. 6) The location influences whether the exudate will be serous or purulent.

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SATA. A client who is recovering following abdominal surgery is lying in bed coughing when you hear him cry out in alarm. When you ask what is wrong, he says he felt something "pop" in his abdomen. You notice increased serosanguineous drainage near the suture line. Which of the following interventions should you take? 1) Maintain the client in bedrest. 2) Cover the wound with sterile towels soaked in sterile saline solution. 3) Notify the surgeon and ready the patient for surgery. 4) Elevate the head of the bed to 20°. 5) Have the client flex his knees. 6) Apply a binder to the abdomen.

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Which factor is known to affect sleep? Select all that apply.. 1) Age 2) Environment 3) Lifestyle 4) State of health 5) Ethnicity

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A new nurse working steady night shift is having difficulty staying awake. What should the nurse do to fight sleepiness on the job? Select all that apply. 1) Plan for rest days. 2) Take frequent breaks. 3) Limit caffeine intake. 4) Do something that is physical. 5) Engage in conversation with others.

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A middle-aged client is overwhelmed with work and says, "Sleep is optional." What should the nurse explain about the importance of sleep to this client's physical, mental, and spiritual health? Select all that apply. 1) Sleep impacts learning. 2) Sleep and illness are not related. 3) Sleep reduces stress and anxiety. 4) Sleep regulates energy metabolism. 5) Sleep affects almost every tissue in the body.

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A client seeks medical attention for a new onset of a sleep disturbance. For which health problem should the nurse assess this client? 1) Diabetes 2) Allergies 3) Heart disease 4) Urinary tract infection

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A patient has difficulty falling asleep despite being very tired. The patient has no physical problems, takes no medications, has quit smoking, eats healthy foods, exercises, and has no changes in sleep routine, stress level, or environment. To what should the nurse relate this patient's Disturbed Sleep Pattern? 1) Increased exercise 2) Nicotine withdrawal 3) Caffeine intake 4) Environmental changes

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On assessing a client, you find a pressure ulcer on the client's back. There is partial-thickness loss of the dermis, and the wound is open but shallow, with a red-pink wound bed. Which stage is this ulcer? 1) Stage I 2) Stage II 3) Stage III 4) Stage IV

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What is the purpose of using a sleep diary? 1) Identify sleep-rest patterns over a 1-year period. 2) Note the trend in sleep-wakefulness patterns over a 2-week period. 3) Note typical sleep habits and most common daily routines. 4) Examine the patterns of sleep during the night and naps during the day.

2

While assessing your client's skin, you observe an irregularly shaped lesion between the inside ankle and the knee. The lesion is red, shiny, taut, and warm. Which type of chronic wound should you suspect in this case? 1) Pressure ulcer 2) Venous stasis ulcer 3) Diabetic ulcer 4) Arterial ulcer

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SATA. You are caring for a client who is at high risk for developing pressure ulcers. Which of the following are intrinsic factors that increase the risk of this client developing pressure ulcers? 1) Friction 2) Impaired sensation due to spinal cord injury 3) Poor nutrition 4) Shearing 5) Edema 6) Compression

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SATA. A primary care provider is deciding on a type of debridement for cleaning a client's wound. The method must be selective, meaning that only dead tissue is removed, while healthy tissue is spared. Which of the following methods will meet this criterion? 1) Sharp debridement 2) Enzymatic debridement 3) Wet-to-dry dressings 4) Whirlpool treatments 5) Autolysis 6) Maggot debridement therapy

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A mother is concerned about a 7-year-old child having nocturnal enuresis three to four times a week. What should the nurse respond to this mother? Select all that apply. 1) "Your daughter's bladder is still developing at this point in her life." 2) "Be patient; most children outgrow enuresis." 3) "Wake your daughter every 4 hours to use the bathroom." 4) "You might consider purchasing protective pads for the bed." 5) "Try a bed alarm to wake her when she starts wetting the bed at night."

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A client becomes confused when aroused so the nurse can provide a treatment. Which stage of sleep was this client most likely experiencing? 1) NI 2) NII 3) NIII 4) REM

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A client has just been prescribed warfarin, an anticoagulant. Which of the following should you mention to the client as a potential skin-related side effect of this medication? 1) Risk for ischemia 2) Inhibited wound healing 3) Hematoma resulting from minimal pressure 4) Increased risk for sunburn

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A client shows you a wound on his hand that he received about a week ago when he fell. You see that the wound is filling in with a beefy red tissue. The client mentions that the wound still bleeds if he applies too much pressure to it. Which phase of healing is this wound in? 1) Hemostasis 2) Inflammatory 3) Proliferative 4) Maturation

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From what stage of sleep are people typically most difficult to arouse? 1) NREM, alpha waves 2) NREM, sleep spindles 3) NREM, delta waves 4) REM

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The nurse notes that a client has been prescribed a polysomnography. For which health problem should the nurse plan care for this client? 1) Diabetes 2) Restless legs syndrome 3) Obstructive sleep apnea (OSA) 4) Chronic obstructive pulmonary disease (COPD)

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The nurse prepares to provide a client with a back massage during evening care. What action should the nurse take before providing this intervention? 1) Provide a warm cup of tea. 2) Provide a prescribed sleeping aid. 3) Check the skin for reddened areas or skin breakdown. 4) Encourage the client to sit in a chair for a short time before the massage.

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What is the impact of benzodiazepines and nonbenzodiazepines on sleep? 1) Benzodiazepines are eliminated from the body faster than are nonbenzodiazepines, so they do not provide a full night of sleep. 2) Nonbenzodiazepines cause daytime sleepiness, allowing people to rest throughout the day. 3) Benzodiazepines produce daytime sleepiness and alter the sleep cycle. 4) Nonbenzodiazepines remain in the body longer than do benzodiazepines.

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What will a person who is deprived of REM sleep for several nights in succession usually experience? 1) Extended NREM sleep 2) Paradoxical sleep 3) REM rebound 4) Insomnia

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Which is the main difference between sleep and rest? 1) In sleep, the body may respond to external stimuli. 2) Short periods of sleep do not restore the body as much as do short periods of rest. 3) Sleep is characterized by an altered level of consciousness. 4) The metabolism slows less during sleep than during rest.

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You are caring for a client who has developed a pressure ulcer. Because of extensive tissue loss in the area of the ulcer, this wound is being left open and allowed to granulate. Which type of healing is this? 1) Regenerative 2) Primary intention 3) Secondary intention 4) Tertiary intention

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The patient is diagnosed with obstructive sleep apnea. What should the nurse expect to assess in this patient? Select all that apply. 1) Bruxism 2) Enuresis 3) Daytime fatigue 4) Snoring 5) Drooling

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A 6-year-old client has a history of sleepwalking at home. Which would be the best nursing diagnosis for this client? 1) Sleep Deprivation related to sleepwalking 2) Fatigue related to sleepwalking 3) Disturbed Sleep Pattern related to dyssomnia 4) Risk for Injury related to sleepwalking

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A client arrives at the emergency room with a long, bleeding cut down her arm caused by smashing through a car window. You recognize this as which of the following types of wounds? 1) Abrasion 2) Contusion 3) Incision 4) Laceration

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A client arrives with a wound that is oozing with a foul-smelling yellow pus. Which type of wound drainage is this? 1) Serous 2) Sanguineous 3) Serosanguineous 4) Purulent

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A patient asks for a carton of milk at bedtime. What action should the nurse take? 1) Withhold the milk because it disrupts REM and slow-wave sleep. 2) Withhold the milk because it interferes with sleep. 3) Withhold the milk because it is a stimulant and will interfere with sleep. 4) Provide the milk because it converts adenosine into serotonin to induce sleep.

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What would be an expected outcome for a client with Disturbed Sleep Pattern? 1) Limit exercise to 1 hour per day early in the day. 2) Consume only one caffeinated beverage per day. 3) Demonstrate effective guided imagery to aid relaxation. 4) Verbalize sleeping better and feeling less fatigued.

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Which is a major factor regulating sleep? 1) Electrical impulses transmitted to the cerebellum 2) Level of sympathetic nervous system stimulation 3) Amount of sleep to which a person has become accustomed 4) Amount of light received through the eyes

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Which patient teaching would be most therapeutic for someone with sleep disturbance? 1) Give yourself at least 60 minutes to fall asleep. 2) Avoid eating carbohydrates before going to sleep. 3) Catch up on sleep by napping or sleeping in when possible. 4) Do not go to bed feeling upset about a conflict.

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8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). a. 4 b. 2 c. 1 d. 7

ANS: A A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry.

20. A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to a. Inspect the wound for bleeding. b. Inspect the wound for foreign bodies. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection.

ANS: A After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.

36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? a. Gentle cleaners and thorough drying of the skin b. Absorbent pads and garments c. Positioning with use of pillows d. Therapeutic beds and mattresses

ANS: A Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown.

15. A patient has developed a decubitus ulcer. What laboratory data would be important to gather? a. Serum albumin b. Creatine kinase c. Vitamin E d. Potassium

ANS: A Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested, but also what the body has absorbed, digested, and metabolized. Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing.

2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is a. Pressure. b. Resistance. c. Stress. d. Weight.

ANS: A Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.

39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage a. I. b. II. c. III. d. IV.

ANS: A Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.

30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a. Ineffective tissue perfusion b. Risk for infection c. Imbalanced nutrition: less than body requirements d. Acute pain

ANS: A The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing diagnosis.

26. The nurse is completing an assessment of the skin's integrity, which includes a. Pressure points. b. All pulses. c. Breath sounds. d. Bowel sounds.

ANS: A The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a binasal cannula and the nares. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part of a skin assessment.

17. The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. b. Notify the charge nurse about the change in status and the potential for infection. c. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). d. Notify the wound care nurse about the change in status and the potential for infection.

ANS: A The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.

14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? a. Complaint by patient that something has given way b. Protrusion of visceral organs through a wound opening c. Chronic drainage of fluid through the incision site d. Drainage that is odorous and purulent

ANS: A occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.

1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel e. Chaplain f. Pharmacist

ANS: A, B, C, D A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special need arises.

5. The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.) a. Inspecting the skin for abrasions and edema b. Covering exposed wounds c. Assessing condition of current dressings d. Assessing the skin at underlying areas for circulatory impairment e. Marking the sites of all abrasions f. Cleansing the area with hydrogen peroxide

ANS: A, B, C, D Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions with a sterile dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean, and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can interfere with wound healing.

3. The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. "Can you easily change your position?" b. "Do you have sensitivity to heat or cold?" c. "How often do you need to use the toilet?" d. "Is movement painful?" e. "What medications do you take?" f. "Have you ever fallen?"

ANS: A, B, C, D Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, he can protect himself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with mobility such as pain will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.

2. The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) a. Nutrition b. Evisceration c. Tissue perfusion d. Infection e. Hemorrhage f. Age

ANS: A, C, D, F Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and decreases the production of proinflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing.

23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? a. Standard mattress b. Nonpowered redistribution air mattress c. Low-air-loss therapy unit d. Lateral rotation

ANS: B A low-air-loss therapy unit is utilized for stage IV pressure ulcers and when prevention or treatment of skin breakdown is needed. If the patient has a stage III or stage IV ulcer or a postoperative myocutaneous flap, the low-air-loss therapy unit would be an appropriate selection. A static air mattress or nonpowered redistribution is utilized for the patient at high risk for skin breakdown. A standard mattress is utilized for an individual who does not have actual or potential altered or impair skin integrity. Lateral rotation is used for treatment and prevention of pulmonary complications associated with mobility.

11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.

ANS: B A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial- thickness repair are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved.

32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a a. Respiratory therapist. b. Registered dietitian. c. Chaplain. d. Case manager.

ANS: B Assessment and a plan for the patient to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote wound healing. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can be consulted when the patient has a discharge need. A chaplain can be consulted when the patient has a spiritual need.

22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step? a. Remove the drain; a drain is no longer needed. b. Call the physician; a blockage is present in the tubing. c. Call the charge nurse to look at the drain. d. As long as the evacuator is compressed, do nothing.

ANS: B Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.

21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a. Don sterile gloves. b. Provide analgesic medications as ordered. c. Avoid accidentally removing the drain. d. Gather supplies.

ANS: B Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure.

35. The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care? a. Sterile technique b. Clean dressings and no touch technique c. Double bagging of contaminated dressings d. Ability of the caregiver

ANS: B Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required for application. The caregiver can use the same no touch technique for dressing changes that is used for changing surface dressings without touching the wound or the surface that might come in contact with the wound. Double bagging is required for the disposal of contaminated dressings. The dressings go in a bag, which is fastened and then placed in the household trash. The ability of the caregiver certainly is a component of the success of home treatment, but it does not influence the cost of supplies.

40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? a. Tell the patient to close his eyes. b. Explain the procedure. c. Turn on the television. d. Ask the family to leave the room.

ANS: B Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient's anxiety.

28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? a. Encourage the patient to sit up in the chair. b. Provide analgesic medication as ordered. c. Explain the risks of immobility to the patient. d. Turn the patient every 3 hours while in bed.

ANS: B Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient's ability to increase mobility.

1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include a. A diet low in calories and fat. b. Alteration in level of consciousness. c. Shortness of breath. d. Muscular pain.

ANS: B Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.

42. The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder? a. The binder creates pressure over the abdomen. b. The binder supports the abdomen. c. The binder reduces edema at the surgical site. d. The binder secures the dressing in place.

ANS: B The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to create pressure over a body part, for example, over an artery after it has been punctured. A binder can be used to prevent edema, for example, in an extremity but is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.

3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? a. The patient ate two thirds of breakfast. b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.

ANS: B The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.

5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage a. I. b. II. c. III. d. IV.

ANS: B This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.) a. Mobility b. Hyperemia c. Induration d. Blanching e. Temperature of skin f. Nutritional status

ANS: B, C, D, E Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and abnormal reactive hyperemia (when the skin turns red after an obstruction of blood flow returns and vasodilatation causes the tissue to turn red). Assess for indurated (hardened) areas on the skin and palpate reddened areas for blanching. Changes in temperature can indicate changes in blood flow to that area of the skin. Mobility and nutritional status are certainly part of the overall assessment for pressure ulcer risk but are not part of the actual skin assessment

6. The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.) a. Ask whether patient's expectations are being met. b. Prevent injury to the skin and tissues. c. Obtain the patient's perception of interventions. d. Reduce injury to the skin. e. Reduce injury to the underlying tissues. f. Restore skin integrity.

ANS: B, D, E, F Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.

29. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain

ANS: C After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.

33. The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient? a. The patient's family will demonstrate specific care of the wound site. b. The patient will state what to look for with regard to an infection. c. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. d. The patient's family members will wash their hands when visiting the patient.

ANS: C Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection; also, this is an intervention, not a goal for this diagnosis. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are interventions, not goals or outcomes for this nursing diagnosis.

25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? a. Use a low-air-loss therapy unit. b. Consult a dietitian. c. Irrigate with hydrogen peroxide. d. Utilize hydrogel dressing.

ANS: C Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.

41. The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? a. Allowing the solution to flow from the most contaminated to the least contaminated b. Scrubbing vigorously when applying solutions to the skin c. Cleansing in a direction from the least contaminated area d. Utilizing clean gauge and clean gloves to cleanse a site

ANS: C Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.

24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes a. Monitoring of the wound. b. Irrigation of the wound. c. Débridement of the wound. d. Management of drainage.

ANS: C Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.

9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? a. Eschar b. Slough c. Granulation d. Purulent drainage

ANS: C Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.

34. The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for a. Infection. b. Impaired skin integrity. c. Trauma. d. Imbalanced nutrition.

ANS: C Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additional trauma. The skin already has impaired integrity owing to the surgical procedure, and because of this has been at risk for infection since the surgical procedure was performed. This patient is of childbearing age and has had a child. Additional needs for nutrition are present during pregnancy and breastfeeding, but this is an established nursing diagnosis. Data are insufficient to support the nursing diagnosis of Imbalanced nutrition.

43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement? a. Monitor vital signs every 15 minutes. b. Apply brace to right knee. c. Elevate right knee and apply ice. d. Check pulses in right foot.

ANS: C Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Applying a brace provides support and decreases the opportunity for additional trauma, which in turn assists in the healing process. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.

16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing? a. Muscular strength assessment b. Sleep assessment c. Pulse oximetry assessment d. Sensation assessment

ANS: C Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment. Oxygen diffuses from the alveoli into the pulmonary blood; most of the oxygen attaches to hemoglobin molecules within the red blood cells. Red blood cells carry oxygenated hemoglobin molecules through the left side of the heart and out to the peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.

7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of a. Primary intention. b. Partial-thickness wound repair. c. Full-thickness wound repair. d. Tertiary intention.

ANS: C Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and remodeling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges approximated. Wound closure is delayed until risk of infection is resolved.

18. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E.

ANS: C Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.

31. The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? a. Teach the family how to manage the odor associated with the wound. b. Discuss with the family how to prepare for care of the patient in the home. c. Encourage thorough handwashing of all individuals caring for the patient. d. Encourage increased quantities of carbohydrates and fats.

ANS: C The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does not relate to the risk of infection. If the patient will be discharged before the wound is healed, the family will certainly need education on how to care for the patient. Teaching the family how to manage the odor associated with a wound is certainly important, but these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process.

19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? a. "I think I will be ready to go home early next week." b. "I am so weak and tired, I want to feel better." c. "I am ready for my bath and linen change as soon as possible." d. "I am hoping there will be something good for dinner tonight."

ANS: C The patient's psychological response to any wound is part of the nurse's assessment. Body image changes can influence self-concept. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens gives you a clue that he or she may be concerned about the smell in the room. The patient stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.

4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? a. Stage I pressure ulcer b. Healing stage II pressure ulcer c. Healing stage III pressure ulcer d. Stage III pressure ulcer

ANS: C When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words "healing stage." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.

37. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a. At least 3 hours b. Not longer than 30 minutes c. Less than 2 hours d. As long as the patient remains comfortable

ANS: C When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.

38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? a. Obtain assistance and use the drawsheet to place the patient into the new position. b. Place the patient in a 30-degree supine position. c. Utilize a transfer sliding board and assistance to slide the patient into the new position. d. Elevate the head of the bed 45 degrees.

ANS: C When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.

27. The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient's Braden scale total score? a. 15 b. 17 c. 20 d. 23

ANS: C With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20.

10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.

ANS: D A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.

13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? a. The incision site has started to itch. b. The incision site is approximated. c. The patient has pain at the incision site. d. The incision has a mass, bluish in color.

ANS: D A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.

12. Which nursing observation would indicate that a wound healed by secondary intention? a. Minimal scar tissue b. Minimal loss of tissue function c. Permanent dark redness at site d. Scarring can be severe.

ANS: D A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.

44. The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? a. 12 b. 13 c. 20 d. 23

ANS: D The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.

6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? a. Cotton-tipped applicator b. Disposable measuring tape c. Sterile gloves d. Halogen light

ANS: D When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first item used.

Why is the information obtained from a swab culture of a wound limited? a)A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria. b)A negative culture may not indicate infection because chronic wounds are often colonized with bacteria. c)Most wound infections are viral, so the swab culture would not be indicative of a wound infection. d)A swab culture result does not include bacterial sensitivity information necessary to provide treatment.

a)A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria.

The patient with a colostomy has been incorrectly applying his ostomy appliance. The continuous contact with liquid stool has caused a skin wound around the ostomy. The nurse assesses bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound? a)Acute, full-thickness, open b)Chronic, partial-thickness, closed c)Acute, partial-thickness, closed d)Chronic, unstageable, open

a)Acute, full-thickness, open

Your patient has a deep wound on the right hip, with tunneling at the 8 o'clock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? a)Alginate dressing b)Dry gauze dressing c)Hydrogel d)Hydrocolloid dressing

a)Alginate dressing

Pressure ulcers are directly caused by which of the following conditions at the site? a)Compromised blood flow b)Edema c)Shearing forces d)Inadequate venous return

a)Compromised blood flow

Which actions would the nurse take when emptying the patient's closed-wound drainage system? Select all that apply. a)Don sterile gloves and personal protective equipment. b)Inspect the drainage tube site and sutures. c)Check that tubing to drainage system is intact. d)Test the suction apparatus at prescribed pressure. e)Document the color, type, and amount of drainage.

a)Don sterile gloves and personal protective equipment. b)Inspect the drainage tube site and sutures. c)Check that tubing to drainage system is intact. d)Test the suction apparatus at prescribed pressure. e)Document the color, type, and amount of drainage.

The home health nurse learns that an elderly patient isn't able to get to the grocery store. She doesn't have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching television, often not realizing that she has bladder leakage. Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply. a)Help her to get out of the chair every 2 hours. b)Change her clothing frequently. c)Bath the patient using soap and water. d)Promote intake of green tea throughout the day. e)Encourage her to wear incontinence products.

a)Help her to get out of the chair every 2 hours. b)Change her clothing frequently e)Encourage her to wear incontinence products.

Why is an accurate description of the location of a wound important? Select all that apply. a)Influences the rate of healing b)Determines the appropriate treatment choice c)Will affect the frequency of dressing changes d)Affects patient movement and mobility

a)Influences the rate of healing b)Determines the appropriate treatment choice d)Affects patient movement and mobility

When applying heat or cold therapy to a wound, what should the nurse do? a)Leave the therapy on each area no longer than 15 minutes. b)Leave the therapy on each area no longer than 30 minutes. c)When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it. d)When using cold, ensure the temperature is less than 32°F (0°C) before applying it.

a)Leave the therapy on each area no longer than 15 minutes.

A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? a)Partial-thickness wound b)Penetrating wound c)Superficial wound d)Full-thickness wound

a)Partial-thickness wound

What is the primary goal that the nurse should establish for a patient with an open wound? a)The wound will remain free of infection throughout the healing process. b)The client will complete antibiotic treatment as ordered. c)The wound will remain free of scar tissue at healing. d)The client will increase caloric intake throughout the healing process.

a)The wound will remain free of infection throughout the healing process.

Which of the following are examples of nonselective mechanical debridement methods? Select all that apply. a)Wet-to-dry dressings b)Sharp debridement c)Whirlpool d)Pulsed lavage

a)Wet-to-dry dressings c)Whirlpool d)Pulsed lavage

Which of the following describes the difference between dehiscence and evisceration? a)With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b)Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. c)Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d)Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

a)With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity? a)Young adult in traction who has a low-protein diet and dehydration b)Elderly patient diagnosed with well-controlled type 2 diabetes c)Middle-aged adult with metabolic syndrome taking antihypertensives d)Adolescent in bed with influenza having periods of high fever and diaphoresis

a)Young adult in traction who has a low-protein diet and dehydration

Of the following, which is the best choice for performing wound irrigation? a)Water jet irrigation b)35-mL syringe with a 19-gauge angiocatheter c)5-mL syringe with a 23-gauge needle d)Bulb syringe

b)35-mL syringe with a 19-gauge angiocatheter

A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? a)Steri-Strips b)Abdominal binder c)T-binder d)Paper tape

b)Abdominal binder

What is a common characteristic of aging skin? a)Increased permeability to moisture b)Diminished sweat gland activity c)Reduced oxygen-free radicals d)Overproduction of elastin

b)Diminished sweat gland activity

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply. a)Granulation b)Hemostasis c)Epithelialization d)Inflammation

b)Hemostasis d)Inflammation

Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives: a)Can cause cellular toxicity b)Increase the risk of ischemia c)Delay wound healing d)Predispose to hematoma formation

b)Increase the risk of ischemia

A man was involved in a motor vehicle accident yesterday. He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? a)Risk for Infection related to subcutaneous injuries b)Risk for Impaired Skin Integrity related to immobility c)Impaired Tissue Integrity related to ventilator dependency d)Impaired Skin Integrity related to ventilator dependency

b)Risk for Impaired Skin Integrity related to immobility

The nurse in the emergency department admits a patient with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing? a)Serous b)Sanguineous c)Purosanguineous d)Purulent

b)Sanguineous

A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: a)Primary intention healing b)Secondary intention healing c)Tertiary intention healing d)Approximation healing

b)Secondary intention healing

While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a)Sanguineous b)Serosanguineous c)Serous d)Purosanguineous

b)Serosanguineous

The patient has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound? a)Pressure ulcer b)Venous stasis ulcer c)Diabetic foot ulcer d)Arterial ulcer

b)Venous stasis ulcer

What are two risk assessment tools used in the United States to evaluate a patient's risk for pressure ulcers? Select all that apply. a)Pressure Ulcer Healing Chart b)PUSH tool c)Braden scale d)Norton scale

c)Braden scale d)Norton scale

The nurse admits an older adult patient to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment? a)Apply transparent film dressings to buttocks. b)Reassess using the Braden Q scale. c)Conduct another assessment in 3 days. d)Massage areas over the bony prominences.

c)Conduct another assessment in 3 days.

What intervention would be most appropriate for a wound with a beefy red wound bed? a)Mechanical debridement b)Autolytic debridement c)Dressing to keep the wound moist and clean d)Removal of devitalized tissue and a sterile dressing

c)Dressing to keep the wound moist and clean

A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? a)Transparent film dressing b)Sheet hydrogel c)Frequent turn schedule d)Enzymatic debridement

c)Frequent turn schedule

A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? a)Dry gauze dressing changed twice daily b)Nonadherent dressing with daily wound care c)Hydrocolloid dressing changed as needed d)Wet-to-dry dressings changed three times a day

c)Hydrocolloid dressing changed as needed

While applying a wet-to-dry dressing, how would the nurse explain to the patient how this procedure works for promoting healing? A wet-to-dry dressing is a: a)Method of submerging the wound in water, allowing it to soak before drying the wound bed b)Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed c)Means of debriding the wound but also removing granulation tissue from the wound d)Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue

c)Means of debriding the wound but also removing granulation tissue from the wound

Which client does the nurse recognize as being at greatest risk for pressure ulcers? a)Infant with skin excoriations in the diaper region b)Young adult with diabetes in skeletal traction c)Middle-aged adult with quadriplegia d)Older adult requiring use of assistive device for ambulation

c)Middle-aged adult with quadriplegia

What is the function of the stratum corneum? a)Provides insulation for temperature regulation b)Provides strength and elasticity to the skin c)Protects the body against the entry of pathogens d)Continually produces new skin cells

c)Protects the body against the entry of pathogens

The nurse learns in report that the assigned patient has a stage III pressure ulcer. What type of tissue does the nurse expect to find in the wound? Select all that apply. a)Muscle b)Eschar c)Subcutaneous d)Dermis e)Fascia

c)Subcutaneous d)Dermis e)Fascia

The patient experiences extensive third-degree burns. What type of healing does the nurse expect? Healing by: a)Primary intention b)Second intention c)Tertiary intention d)Primary intention if no infection occurs

c)Tertiary intention

When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? a)The patient will need to take antibiotics until the wound is completely healed. b)Because the patient's wound was left open, the wound will likely become infected. c)The patient will have more scar tissue formation than there would be for a wound closed at surgery. d)The patient should expect to remain hospitalized until complete wound healing occurs.

c)The patient will have more scar tissue formation than there would be for a wound closed at surgery.

For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? a)Client will maintain intact skin throughout hospitalization. b)Client will limit pressure to wound site throughout treatment course. c)Wound will close with no evidence of infection within 6 weeks. d)Wound will improve prior to discharge as evidenced by a decrease in drainage.

c)Wound will close with no evidence of infection within 6 weeks.

An adult patient is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The patient has no problem with rubbing, friction, or shear. What is the Braden score for this patient? a)0 b)15 c)20 d)23

d)23

The nurse is caring for a patient with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply? a)Alginate b)Antimicrobial petroleum gauze c)Foam dressing d)Antimicrobial collagen dressings

d)Antimicrobial collagen dressings

A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patient's left heel. What is the initial treatment for this pressure ulcer? a)Antibiotic treatment for 2 weeks b)Normal saline irrigation of the ulcer daily c)Debridement to the left heel d)Elevation of the left heel off the bed

d)Elevation of the left heel off the bed

What is the primary difference between acute and chronic wounds? Chronic wounds: a)Are full-thickness wounds, but acute wounds are superficial b)Result from pressure, but acute wounds result from surgery c)Are usually infected, whereas acute wounds are contaminated d)Exceed the typical healing time, but acute wounds heal readily

d)Exceed the typical healing time, but acute wounds heal readily

The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? a) Is actively bleeding b) Has swollen, tender insect bite c) Has just sprained her ankle d)Has lower back pain

d)Has lower back pain

Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: a)Remove all of the soiled dressings before beginning wound treatment b)Cleanse wounds from most contaminated to least contaminated c)Treat wounds on the patient's side first, then the front and back of the patient d)Irrigate wounds from least contaminated to most contaminated

d)Irrigate wounds from least contaminated to most contaminated

The nurse would question a prescription for application of cold therapy to which patient? The patient with a: a)Wound oozing blood b)Sprained wrist c)Infected wound d)Pressure ulcer

d)Pressure ulcer

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client a)Begins an aggressive exercise program b)Follows a diet plan of 1,200 calories per day c)Is fitted for deep-depth diabetic footwear d)Remains free of foot wounds

d)Remains free of foot wounds

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? a)Stage I pressure ulcer, healing b)Stage II pressure ulcer, healing c)Stage III pressure ulcer, healing d)Stage IV pressure ulcer, healing

d)Stage IV pressure ulcer, healing

A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? a)Primary intention b)Regenerative healing c)Secondary intention d)Tertiary intention

d)Tertiary intention

The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: a)The ulcer is completely healed with minimal scarring b)The patient reports no pain at the site c)A minimal amount of drainage is noted d)The wound bed contains 100% granulated tissue

d)The wound bed contains 100% granulated tissue

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? a)Stage II pressure ulcer b)Stage III pressure ulcer c)Stage IV pressure ulcer d)Unstageable pressure ulcer

d)Unstageable pressure ulcer

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? a)Draw a circle around the area of drainage on a dressing. b)Classify drainage as less or more than the previous drainage. c)Weigh the patient at the same time each day on the same scale. d)Weigh dressings before they are applied and after they are removed.

d)Weigh dressings before they are applied and after they are removed.