Chapter 35: Skin Integrity, and Wound Healing Practice Questions
The nurse in the emergency department admits a client 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? 1. Serous 2. Sanguineous 3. Purosanguineous 4. Purulent
2. Sanguineous
The nurse is assessing the client who 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? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4
2. Stage 2
The client 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? 1. Pressure ulcer 2. Venous stasis ulcer 3. Diabetic foot ulcer 4. Arterial ulcer
2. Venous stasis ulcer
Which of the following clients does the nurse recognize as being at greatest risk for pressure ulcers? 1. An infant with skin excoriations in the diaper region 2. A young adult with diabetes in skeletal traction 3. A middle-aged adult with quadriplegia 4. An older adult requiring use of assistive device for ambulation
3. A midde-aged adult with quadriplegia
The nurse is providing care to the client that has experienced extensive third-degree burns. The nurse is aware that this client will have what type of healing? 1. Primary intention 2. Second intention 3. Tertiary intention 4. Primary intention if no infection occurs
3. Tertiary intention
The nurse is caring for a client 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? 1. Alginate 2. Antimicrobial petroleum gauze 3. Foam dressing 4. Antimicrobial collagen dressings
4. Antimicrobial collagen dressings
The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client: 1. Begins an aggressive exercise program 2. Follows a diet plan of 1,200 calories per day 3. Is fitted for deep-depth diabetic footwear 4. Remains free of foot wounds
4. Remains free of foot wounds
The nurse is preparing to apply cold therapy. Which of the following diagnoses are contraindicated for cold therapy? 1. The client with a bleeding wound 2. The client with a sprained wrist 3. The client with an infected wound 4. The client with a pressure ulcer
4. The client with a pressure ulcer
The nurse is preparing to provide care to the client who 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? 1. Primary intention 2. Regenerative healing 3. Secondary intention 4. Tertiary intention
4. tertiary intention
An adult client 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 client has no problem with rubbing, friction, or shear. What is the Braden score for this client? 1. 10 2. 15 3. 20 4. 23
4. 23
The nurse is preparing to perform a dressing change on the client who has a wound. The nurse notes this is 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 serosanguinous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? 1. Alginate dressing 2. Dry gauze dressing 3. Hydrogel 4. Hydrocolloid dressing
1. Alginate dressing
The nurse obtains a swab culture from a chronic wound and understands that this may have limited findings. Why is the information obtained from a swab culture of a wound limited? 1. A positive culture does not necessarily indicate infection because chronic wounds are often colonized by bacteria. 2. A negative culture may not indicate infection because chronic wounds are often colonized by bacteria. 3. Most wound infections are viral, so the swab culture would not be indicative of an infection. 4. A swab culture result does not include bacterial sensitivity information necessary to provide treatment.
1. A positive culture does not necesarily indicate infection becuse chronic wounds are foten colonized by bacteria
The nurse assesses assigned clients and determines which client is at highest risk for altered skin integrity? 1. A young adult in traction who has a low-protein diet and dehydration 2. An older client diagnosed with well-controlled type 2 diabetes 3. A middle-aged adult with metabolic syndrome taking antihypertensives 4. An adolescent in bed with influenza, having periods of high fever and diaphoresis
1. A young adult in traction who has a low-protein diet and dehydration
The nurse assesses the surrounding skin of the client's colostomy. The client has been incorrectly applying his ostomy appliance and which caused a wound due to the continuous contact with liquid stool. The nurse notes bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound? 1. Acute, full-thickness, open 2. Chronic, partial-thickness, closed 3. Acute, partial-thickness, closed 4. Chronic, unstageable, open
1. Acute, full-thickness, open
The nurse is reviewing the client's surgical report and notes that the client has a history of evisceration. The nurse researches the differences between dehiscence and evisceration. Which of the following describes the difference between dehiscence and evisceration? 1. Dehiscence involves a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. 2. Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. 3. 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. 4. Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.
1. Dehiscence inolves a separation of one or more layers of wound tissue, evisceration involves the protrusion of internal viscera from the incision site
The home health nurse learns that an elderly client 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. 1. Help her to get out of the chair every 2 hours. 2. Change her clothing frequently. 3. Bath the client using soap and water. 4. Promote intake of green tea throughout the day. 5. Encourage her to wear incontinence products.
1. Help her to get out of the chiar every 2 hours 2. Change her clothing frequenlty 5. Encoruage her to wear incontinence products
Why is an accurate description of the location of a wound important? Select all that apply. 1. Influences the rate of healing 2. Determines the appropriate treatment choice 3. Will affect the frequency of dressing changes 4. Affects client movement and mobility 5. Provides cues of wound etiology
1. Infleunces the rate of healing 2. Determines the appropriate treatment choice 4. Affects client movement and mobility 5. Provides cues of wound etiology
The nurse recognizes that pressure ulcers are directly caused by which of the following conditions at the site? 1. Ischemia 2. Edema 3. Shearing forces 4. Vascular issues
1. Ischemia
The nurse is preparing to apply heat therapy alternated with cold therapy to a wound. What is the proper method for this therapy? 1. Leave the therapy on each area no longer than 15 minutes. 2. Leave the therapy on each area no longer than 30 minutes. 3. When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it. 4. When using cold, ensure the temperature is less than 32°F (0°C) before applying it.
1. Leave the therapy on each area no longer than 15 minutes
Which of the following are examples of nonselective mechanical debridement methods? Select all that apply. 1. Wet-to-dry dressings 2. Sharp debridement 3. Whirlpool 4. Pulsed lavage 5. Foam alginate
1. Wet- to- dry dressings 3. Whirlpool 4. Pulsed lavage
The client is status post 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? 1. Steri-Strips 2. Abdominal binder 3. T-binder 4. Paper tape
2, Abdominal binder
The nurse is preparing to perform a wound irrigation. Which of the following is the best choice for performing wound irrigation? 1. Sterile water jet irrigation 2. 35-mL syringe with a 19-gauge angiocatheter 3. 5-mL syringe with a 23-gauge needle 4. Clean bulb syringe and canister
2. 35-ml syringe with a 19-gauge angiocatheter
The nurse understands that the client who takes antihypertensive medications is at risk for compromised skin integrity and poor wound healing. What is the rationale for that understanding? 1. Antihypertensives can cause cellular toxicity. 2. Antihypertensives increase the risk of ischemia. 3. Antihypertensives can delay wound healing. 4. Antihypertensives predispose to hematoma formation.
2. Antihypertensive inceases the risk of ischemia
Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply. 1. Granulation 2. Hemostasis 3. Epithelialization 4. Inflammation 5. Maturation
2. Hemostais 4. Inflammation
Which actions would the nurse take when emptying the client's closed-wound drainage system? Select all that apply. 1. Don sterile gloves and personal protective equipment. 2. Inspect the drainage tube site and suture sites. 3. Check that tubing to drainage system is intact. 4. Test the suction apparatus at the prescribed pressure. 5. Document the color, type, and amount of drainage.
2. Inspect the drainage tube site and suture sites 3. Check that tubing to drainage system is intact 4. Test the suction apparatus at the prescribed pressure 5. Document thee color, type and amount of drainage
The nurse documents that the new wound has serosanguineous drainage. How is serosanguineous described? 1. Bloody 2. Red, watery, clear 3. Purulent drainage 4. Straw colored
2. Red, watery, clear
The nurse is developing a plan of care for a client who was injured in a motor vehicle accident yesterday. The client 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? 1. Risk for Infection related to subcutaneous injuries 2. Risk for Impaired Skin Integrity related to immobility 3. Impaired Tissue Integrity related to ventilator dependency 4. Impaired Skin Integrity related to ventilator dependency
2. Risk for impaired skin integrity related to immobility
The nurse is reviewing a wound care nurse's narrative note that states there is a fistula in the lower abdominal wall as a result of a poorly healing surgical wound. What is a common cause of a fistula? 1. Ischemic pressure to a bony prominence 2. Diminished venous return to the site 3. Abscess formation from infection or debris 4. Abnormal straining over the incisional site
3. Abscess formation from infection or debris
Which of the following are the two risk assessment tools most commonly used in the United States to evaluate a client's risk for pressure ulcers? Select all that apply. 1. Pressure Ulcer Healing Chart 2. PUSH tool 3. Braden scale 4. Norton scale 5. Braden Q Scale
3. Braden scale 4. Norton scale 5. Braden Q scale
The nurse admits an older adult client to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment? 1. Apply transparent film dressings to buttocks. 2. Reassess by using the Braden Q scale. 3. Conduct another assessment in 3 days. 4. Massage areas over the bony prominences.
3. Conduct another assessment in 3 days
What type of wound can be described as a superficial wound, usually self-inflicted due to excessive scratching or mechanical force? 1. Laceration 2. Contusion 3. Excoriation 4. Incision
3. Excoriation
A client has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage 1 pressure ulcer. What would be the most important treatment for this client? 1. Transparent film dressing 2. Sheet hydrogel 3. Frequent turn schedule 4. Enzymatic debridement
3. Frequent turn schedule
The nurse is preparing to perform wound care for the client that has a stage 2 pressure ulcer on their 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? 1. Dry gauze dressing changed twice daily 2. Nonadherent dressing with daily wound care 3. Hydrocolloid dressing changed as needed 4. Wet-to-dry dressings changed three times a day
3. Hydrocolloid dressing changes as needed
While applying a wet-to-dry dressing, how would the nurse explain to the client how this procedure works for promoting healing? A wet-to-dry dressing is a: 1. Method of submerging the wound in water, allowing it to soak before drying the wound bed 2. Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed 3. Means of debriding the wound but also removing granulation tissue from the wound 4. Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue
3. Means of debriding the wound but also removin granulation tisse from the wound
The nurse is assessing the client's wound and notes that the wound bed shows granulation. What phase of wound healing is described by the nurse's note? 1. Hemostasis 2. Inflammation 3. Proliferative 4. Maturation
3. Proliferative
A client underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: 1. Approximation intention healing 2. Primary intention healing 3. Secondary intention healing 4. Tertiary intention healing
3. Secondary intention healing
The nurse learns in report that the assigned client has a stage 3 pressure ulcer. What type of tissue does the nurse expect to visualize in the wound? Select all that apply. 1. Muscle 2. Eschar 3. Subcutaneous tissue 4. Dermis 5. Fascia
3. Subcutaneous tissue 4. Dermis 5. Fascia
The nurse is developing a teaching plan for a client that has a surgical incision that has been left open. Which of the following points would the nurse make? 1. The client will need to have twice daily wet to dry dressing changes until the wound is completely healed. 2. The client will need to start a course of antibiotics for the infection until the wound is completely healed. 3. The client will have more scar tissue formation than there would be for a wound closed at surgery. 4. The client should expect to remain hospitalized in an isolation room until the wound is completely healed.
3. The client will have more scar tissue formation than there would be for a wound closed at surgery
The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. There is a notation that states there is an absence of the stratum corneum. Which of the following explains why this is a concern? 1. The stratum corneum provides insulation for temperature regulation. 2. The stratum corneum promotes strength and elasticity to the skin. 3. The stratum corneum protects the body against the entry of pathogens. 4. The stratum corneum produces new skin cells on a continuing basis.
3. The stratum cornuem protects the body agains the entry of pathogens
The nurse is developing plan of care for the client with a stage 4 pressure ulcer, what would an applicable client goal/outcome be? 1. Client will maintain intact skin throughout hospitalization. 2. Client will limit pressure to wound site throughout treatment course. 3. Wound will close with no evidence of infection within 6 weeks. 4. Wound will improve prior to discharge as evidenced by a decrease in drainage.
3. Wound will close with no evidence of infection within 6 weeks
The nurse is assessing the client with a wound that is considered chronic. The client asks the nurse to explain the difference between chronic and acute wounds. Which of the following would best describe the primary difference between chronic and acute? 1. Chronic wounds are often full-thickness wounds, but acute wounds are superficial. 2. Chronic wounds are the result of pressure, but acute wounds result from surgery. 3. Chronic wounds are usually infected, whereas acute wounds are contaminated. 4. Chronic wounds exceed the typical healing time, but acute wounds heal readily.
4. Chronic wounds exceed the typical healing time, but acute wounds heal readily
The nurse is providing care to the client who is 2 days status post cerebrovascular accident with residual decreased left-sided mobility. During the assessment, the nurse discovers a stage 1 pressure area on the client's left heel. What is the initial treatment for this pressure ulcer? 1. Antibiotic treatment for 2 weeks 2. Normal saline irrigation of the ulcer daily 3. Debridement to the left heel 4. Elevation of the left heel off the bed
4. Elevation of the left heal off the bed
The nurse is preparing to provide wound care to a client with many open wounds. Which of the following actions would be the most appropriate method for dressing changes of multiple open wounds that require treatment? 1. Remove all of the soiled dressings before beginning wound treatment. 2. Cleanse wounds from the most contaminated area to the least contaminated area. 3. Treat wounds on the client's side first and then the front and back of the client. 4. Irrigate wounds from the least contaminated area to the most contaminated area.
4. Irrigatte wounds from the least contaminiaed area to the ost contaiminated area
A client developed a stage 4 pressure ulcer in 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? 1. Stage 1 pressure ulcer, healing 2. Stage 2 pressure ulcer, healing 3. Stage 3 pressure ulcer, healing 4. Stage 4 pressure ulcer, healing
4. Stage 4 pressure ulcer, healing
The nurse working in the emergency department is preparing heat therapy for one of the clients in the unit. Which one is it most likely to be? 1. The client who is actively bleeding 2. The client who has swollen, tender insect bite 3. The client who has just sprained her ankle 4. The client who has lower back pain
4. The client who has lower back pain
Which of the following would be the most appropriate outcome for the client with a stage 2 pressure ulcer? 1. The ulcer is completely healed with minimal scarring. 2. The client reports no pain at the site. 3. A minimal amount of drainage is noted. 4. The wound bed contains 100% granulated tissue.
4. The wound bed contains 100% granulated tissue
A client hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. There is a pressure area on the client's coccyx measuring 5 × 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? 1. Stage 2 pressure ulcer 2. Stage 3 pressure ulcer 3. Stage 4 pressure ulcer 4. Unstageable pressure ulcer
4. Unstagebale pressure ulcer
The nurse is assessing a client that has an underlying cardiac disease and a draining wound, all of which requires careful monitoring of his fluid balance. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? 1. Draw a circle around the area of drainage on a dressing. 2. Classify drainage as less or more than the previous drainage. 3. Weigh the client at the same time each day on the same scale. 4. Weigh dressings before they are applied and after they are removed.
4. Weigh dressings before they are applied and after they are removed
