Chapter 48 (Skin Integrity & Wound Care)

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. "What medications do you take?" E. "Is movement painful?" F. "Have you ever fallen?"

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?" E. "Is movement painful?"

As prescribed, the nurse leaves the pressure ulcer open to air and does not apply a dressing. Which stage of ulcer did the nurse appropriately treat? A. A Stage I B. A Stage II C. A Stage III D. A Stage IV

A. A Stage I

The nurse is caring for a patient at risk for skin impairment. Which initial action should the nurse take to decrease this risk? A. After cleansing thoroughly dry the skin. B. Request a therapeutic bed and mattress. C. Pad the bed with absorbent pads. D. Use products that retain moisture.

A. After cleansing thoroughly dry the skin.

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. Which action will the nurse take initially? A. Call the health care provider; a blockage is present in the tubing. B. Chart the results on the intake and output flow sheet. C. Do nothing, as long as the evacuator is compressed. D. Remove the drain; a drain is no longer needed.

A. Call the health care provider; a blockage is present in the tubing.

Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to? A. Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results B. Notifying the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR) C. Consulting the wound care nurse about the change in status and the potential for infection D. Conferring with the charge nurse about the change in status and the potential for infection

A. Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient? A. Low-air-loss B. Air-fluidized C. Lateral rotation D. Standard mattress

B. Air-fluidized

When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)? A. Assessing a surgical patient for risk of pressure ulcers B. Applying a gauze bandage to secure a nonsterile dressing C. Treating a pressure ulcer on the buttocks of a medical patient D. Implementing negative-pressure wound therapy on a stable patient

B. Applying a gauze bandage to secure a nonsterile dressing

The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.) A. The patient's expectations are not being met. B. Skin is intact with no redness or swelling. C. Nonblanchable erythema is absent. D. No injuries to the skin and tissues are evident. E. Granulation tissue is present.

B. Skin is intact with no redness or swelling. C. Nonblanchable erythema is absent. D. No injuries to the skin and tissues are evident. E. Granulation tissue is present.

The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV

B. Stage II

The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed? A. 12 B. 13 C. 20 D. 23

D. 23

The nurse is caring for a postoperative patient recovering from a medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management? A. Monitor vital signs every 15 minutes. B. Check pulses in the right foot. C. Keep the leg dependent. D. Apply ice.

D. Apply ice.

Which is the best explanation for the nurse to provide when teaching the patient the reason for the binder after an open abdominal aortic aneurysm repair? A. It reduces edema at the surgical site. B. It secures the dressing in place. C. It immobilizes the abdomen. D. It supports the abdomen.

D. It supports the abdomen.

Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient? A. Disposable measuring tape B. Cotton-tipped applicator C. Sterile gloves D. Natural light

D. Natural light

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? A. Partial-thickness repair B. Secondary intention C. Tertiary intention D. Primary intention

D. Primary intention

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility? A. Explain the risks of immobility to the patient. B. Turn the patient every 3 hours while in bed. C. Encourage the patient to sit up in the chair. D. Provide analgesic medication as ordered.

D. Provide analgesic medication as ordered.

Which nursing observation will indicate the patient's wound healed by the process of secondary intention? A. Minimal loss of tissue function B. Permanent dark redness at site C. Minimal scar tissue D. Scarring that may be severe

D. Scarring that may be severe

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan? A. Readiness for enhanced nutrition B. Impaired physical mobility C. Impaired skin integrity D. Chronic pain

C. Impaired skin integrity

Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer? A. Vitamin E B. Potassium C. Prealbumin D. Sodium

C. Prealbumin

The nurse is caring for a patient who will have a large abdominal bandage secured with an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.) A. Cover exposed wounds. B. Mark the sites of all abrasions. C. Assess the condition of current dressings. D. Inspect the skin for abrasions and edema. E. Cleanse the area with hydrogen peroxide. F. Assess the skin at underlying areas for circulatory impairment.

A. Cover exposed wounds. C. Assess the condition of current dressings. D. Inspect the skin for abrasions and edema. F. Assess the skin at underlying areas for circulatory impairment.

A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development? A. Decreased level of consciousness B. Adequate dietary intake C. Shortness of breath D. Muscular pain

A. Decreased level of consciousness

Which nursing observation will indicate the patient is at risk for pressure ulcer formation? A. Fecal incontinence B. Ate two thirds of breakfast C. A raised red rash on the right shin D. Capillary refill is less than 2 seconds

A. Fecal incontinence

The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.) A. Hemostasis B. Maturation C. Inflammatory D. Proliferative E. Reproduction F. Reestablishment of epidermal layers

A. Hemostasis B. Maturation C. Inflammatory D. Proliferative

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, what is the next best step for the nurse to take? A. Inspect the wound for bleeding. B. Irrigate the wound to remove foreign bodies. C. Measure and document the size of the wound. D. Determine when the patient last had a tetanus antitoxin injection.

A. Inspect the wound for bleeding.

A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair? A. Less than 2 hours at any one time B. For a total of least than 3 hours daily C. No longer than 30 minutes out of every hour D. Until the patient expresses being uncomfortable

A. Less than 2 hours at any one time

The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.) A. Place moist sterile gauze over the site. B. Gently place the organs back. C. Contact the surgical team. D. Offer a glass of water. E. Monitor for shock.

A. Place moist sterile gauze over the site. C. Contact the surgical team. E. Monitor for shock.

The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority? A. Pressure points B. Breath sounds C. Bowel sounds D. Pulse points

A. Pressure points

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 action should the nurse take first? A. Provide analgesic medications as ordered. B. Avoid accidentally removing the drain. C. Don sterile gloves. D. Gather supplies.

A. Provide analgesic medications as ordered.

The nurse is caring for a patient who is experiencing a full-thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing? A. Eschar B. Slough C. Granulation D. Purulent drainage

C. Granulation

The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record? A. Stage I pressure ulcer B. Healing Stage II pressure ulcer C. Healing Stage III pressure ulcer D. Stage III pressure ulcer

C. Healing Stage III pressure ulcer

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? A. Partial-thickness wound repair B. Full-thickness wound repair C. Primary intention D. Tertiary intention

B. Full-thickness wound repair

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.) A. Vision B. Hyperemia C. Induration D. Blanching E. Temperature of skin

B. Hyperemia C. Induration D. Blanching E. Temperature of skin

The nurse documents the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? A. Imbalanced nutrition: less than body requirements B. Ineffective peripheral tissue perfusion C. Risk for infection D. Acute pain

B. Ineffective peripheral tissue perfusion

The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question? A. Use a low-air-loss therapy unit. B. Irrigate with Dakin's solution. C. Apply a hydrogel dressing. D. Consult a dietitian.

B. Irrigate with Dakin's solution.

The patient appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take? A. Distract the patient with the television. B. Offer to explain what they should expect. C. Suggest that the patient "Close your eyes." D. Wait until family is visiting to support the patient.

B. Offer to explain what they should expect.

The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development of a decubitus ulcer? A. Resistance B. Pressure C. Weight D. Stress

B. Pressure

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian? A. Fat B. Protein C. Vitamin E D. Carbohydrate

B. Protein

A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing? A. Muscular strength assessment B. Pulse oximetry assessment C. Sensation assessment D. Sleep assessment

B. Pulse oximetry assessment

Which health care team member will the nurse consult when a patient has received a nursing diagnosis of Impaired skin integrity? A. Respiratory therapist B. Registered dietitian C. Case manager D. Chaplain

B. Registered dietitian

The nurse caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient? A. Partial-thickness repair B. Secondary intention C. Tertiary intention D. Primary intention

B. Secondary intention

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. Which is the best method for repositioning the patient? A. Place the patient in a 30-degree supine position. B. Utilize a transfer device to lift the patient. C. Elevate the head of the bed 45 degrees. D. Slide the patient into the new position.

B. Utilize a transfer device to lift the patient.

The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain is currently in place. Which statement by the patient indicates issues with self-concept? A. "I am so weak and tired. I just want to feel better." B. "I been thinking I will be ready to go home early next week." C. "I really need a bath and linen change right; I feel so awful." D. "I am hoping there will be something good to eat for my dinner tonight."

C. "I really need a bath and linen change right; I feel so awful."

The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has 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. Which score will the nurse document for this patient? A. 15 B. 17 C. 20 D. 23

C. 20

The nurse is caring for a group of patients. Which patient will the nurse see first? A. A patient with a Stage IV pressure ulcer B. A patient with a Braden Scale score of 18 C. A patient with appendicitis using a heating pad D. A patient with an incision that is approximated

C. A patient with appendicitis using a heating pad

Which intervention should be included as the nurse cleanses a wound? A. Allow the solution to flow from the most contaminated to the least contaminated. B. Scrub vigorously when applying noncytotoxic solution to the skin. C. Cleanse in a direction from the least contaminated area. D. Utilize clean gauze and clean gloves to cleanse a site.

C. Cleanse in a direction from the least contaminated area.

The nurse caring for an immobile patient wants to decrease the risk of the formation of pressure ulcers. Which action will the nurse take first? A. Offer favorite fluids. B. Turn the patient every 2 hours. C. Determine the patient's risk factors. D. Encourage increased quantities of carbohydrates and fats.

C. Determine the patient's risk factors.

Which finding will alert the nurse to a potential wound dehiscence? A. Protrusion of visceral organs through a wound opening B. Chronic drainage of fluid through the incision site C. Report by patient that something has given way D. Drainage that is odorous and purulent

C. Report by patient that something has given way

The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient? A. Increased monitoring of the wound condition B. Documenting the wound's status daily C. Surgical debridement of the wound D. Increased drainage from wound

C. Surgical debridement of the wound

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the patient is experiencing a complication of wound healing? A. Patient reporting, "My incision is hurting." B. Approximation of the incision edges has occurred. C. Patient asks, "Why has my incision started to itch?" D. The incision appears both swollen and bluish in color.

D. The incision appears both swollen and bluish in color.

When a comatose patient develops a Stage II pressure ulcer, the nurse includes the nursing diagnosis of Risk for infection to the care plan. Which is the best goal for this patient? A. The patient will state what to look for with regard to an infection. B. The patient's family will demonstrate specific care of the wound site. C. The patient's family members will wash their hands when visiting the patient. D. The patient will remain free of odorous or purulent drainage from the wound.

D. The patient will remain free of odorous or purulent drainage from the wound.