Skin and wound

What is the correct sequence of steps when performing a wound irrigation? 1. Use slow continuous pressure to irrigate wound. 2. Attach angio catheter to syringe 3. Fill syringe with irrigation fluid 4. Place water proof bag near bed 5. Position angio catheter over wound A. 4, 3, 2, 5, 1 B. 3, 4, 2, 1, 5 C. 4, 2, 3, 5, 1 D. 2, 3, 4, 5, 1

A. 4, 3, 2, 5, 1 Organized steps ensure a safe effective irrigation of the wound.

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

A. Complaint by patient that something has given way. 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.

When is an application of a warm compress to an ankle muscle sprain indicated? Select all that apply. A. To relieve edema B. To reduce shivering C. To improve blood flow to an injured part D. To protect bony prominences from pressure ulcers E. To immobilize area

A. To relieve edema C. To improve blood flow to an injured part Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

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

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

What does the Braden Scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk for skin breakdown C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk for poor healing

B. Risk factors that place the patient at risk for skin breakdown. The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

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.

C. Full-thickness wound repair. 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.

What is not included in a skin integrity assessment?

Pressure points

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

C. Granulation Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.

A client who had abdominal surgery 24 hours ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply) A. Cover the area with salon-soaked sterile dressings. B. Apply and abdominal binder snugly around the abdomen. C. Use a sterile gauze to apple gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. Offer the client a warm beverage (herbal tea)

A. Cover the area with salon-soaked sterile dressings. Cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. D. Position the client supine with the hips and knees bent. Open burn areas heal by secondary intension, which is the process for wounds that have tissue loss and widely separated edges.

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

A. 4 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.

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?

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? 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.

What is the removal of devitalized tissue from a wound called? A. Debridement B. Pressure reduction C. Negative pressure wound therapy D. Sanitization

A. Debridement Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? Select all that apply. A. Frequent position changes. B. Keeping the buttocks exposed to air at all times C. Using a large absorbent diaper, changing when saturated D. Using an incontinence cleaner E. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel F. Applying a moisture barrier ointment

A. Frequent position changes. D. Using an incontinence cleaner F. Applying a moisture barrier ointment Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin care and moisture barriers must also be used with frequent position changes to assist in reducing the risk for pressure ulcers.

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply) A. Increase in incisional pain. B. Fever and chills. C. Reddened wound edges. D. Increase in serosanguineous drainage E. Decrease in thirst.

A. Increase in incisional pain. Expect the client to have pain and tenderness at the wound site with an incisional infection. B. Fever and chills. Expect the client to have fever and chills with an incisional infection. C. Reddened wound edges. Expect the client to have a reddened wound edges with an incisional infection.

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.

B. Secondary intention. 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 nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (Select all that apply) A. Keep the head of the bed elevated 30 degrees. B. Massage the clients bony provinces frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in the chair. E. Reposition the client at least every 3 hours when in bed.

A. Keep the head of the bed elevated 30 degrees. Slightly elevate the head of the clients bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. D. Have the client sit on a gel cushion when in the chair. Have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas.

Match the pressure ulcer categories/stages with the correct definition. A. Category/Stage I B. Category/Stage II C. Category/Stage III D. Category/Stage IV

A. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. B. Partial thickness skin loss or intact blister with serosanginous fluid. C. Full thickness skin loss, subcutaneous fat may be visible. Many include undermining. D. Full thickness tissue loss, muscle and bone visible. May include undermining.

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? Select all that apply. A. Notify the surgeon B. Allow the area to be exposed to air until all drainage has stopped C. Place several cold packs over the area, protecting the skin around the wound D. Cover the area with sterile, saline-soaked towels and immediately. E. Cover the area with sterile gauze and apply an abdominal binder

A. Notify the surgeon. D. Cover the area with sterile, saline-soaked towels and immediately. If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

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

A. Registered dietitian B. Enterostomal and wound care nurse C. Physical therapist D. Case management personnel 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.

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

A. Serum albumin 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.

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply) A. Stage 3 pressure injury B. Sutured surgical incision. C. Casted bone fracture. D. Laceration sealed with adhesive. E. Open burn area.

A. Stage 3 pressure injury Open pressure ulcers heal by secondary intension, which is the process for wounds that have tissue loss and widely separated edges. E. Open burn area. Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.

Which of the following are measures to reduce tissue damage from shear? Select all that apply. A. Use a transfer device, e.g. transfer board B. Have head of bed elevated when transferring patient C. Have head of bed flat when re positioning patients D. Raise head of bed 60 degrees when patient positioned supine E. Raise head of bed 30 degrees when patient positioned supine

A. Use a transfer device, e.g. transfer board. C. Have head of bed flat when re-positioning patients. E. Raise head of bed 30 degrees when patient positioned supine. A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed to be elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position will cause patient to slide down, causing shear.

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.

B. Alteration in level of consciousness. 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.

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 nurses 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.

B. Call the physician; a blockage is present in the tubing. 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.

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply) A. Extremes in age. B. Chronic illness. C. Low hemoglobin D. Malnutrition E. Poor wound care.

B. Chronic illness. Diabetes mellitus is a chronic illness that places additional stress on the body healing mechanisms. C. Low hemoglobin Hgb is essential for oxygen delivery to healing tissues, and this clients Hgb level is low. D. Malnutrition A BMI of 17.1 indicates that the client is underweight and, therefore, malnourished.

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

B. Clean dressings and no touch technique 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.

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.

B. II. 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.

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? A. Binder B. Ice bag C. Elastic bandage D. Absorptive dressing

B. Ice bag An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

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 patients expectations are being met. B. Prevent injury to the skin and tissues. C. Obtain the patients perception of interventions. D. Reduce injury to the skin. E. Reduce injury to the underlying tissues. F. Restore skin integrity.

B. Prevent injury to the skin and tissues. D. Reduce injury to the skin. E. Reduce injury to the underlying tissues. F. Restore skin integrity. 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 patients perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.

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.

B. Provide analgesic medications as ordered. 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.

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? Select all that apply. A. Collection of wound drainage B. Provides support to abdominal tissues when coughing or walking C. Reduction of abdominal swelling D. Reduction of stress on the abdominal incision. E. Stimulation of peristalsis (return of bowel function) from direct pressure

B. Provides support to abdominal tissues when coughing or walking. D. Reduction of stress on the abdominal incision. A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

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.

B. The binder supports the abdomen. 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.

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 patients capillary refill is less than 2 seconds.

B. The patient has fecal incontinence. 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

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.

C. I am ready for my bath and linen change as soon as possible. The patients psychological response to any wound is part of the nurses assessment. Body image changes can influence self-concept. Factors that affect the patients 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 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.

C. Irrigate with hydrogen peroxide. Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakins solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds.

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

C. Less than 2 hours 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.

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.

C. Protein. 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.

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

C. Pulse oximetry assessment. 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.

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 patients 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 patients family members will wash their hands when visiting the patient.

C. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. 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.

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? A. Category/Stage II B. Category/Stage IV C. Unstageable D. Suspected deep tissue damage

C. Unstageable. To determine the category/stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

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.

C. Utilize a transfer sliding board and assistance to slide the patient into the new position. When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patients body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries.

Which of the following describes a hydrocolloid dressing? A. A seaweed derivative that is highly absorptive B. Premoistened gauze placed over a granulating wound C. A debriding enzyme that is used to remove necrotic tissue D. A dressing that forms a gel that interacts with the wound surface

D. A dressing that forms a gel that interacts with the wound surface. A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage III pressure ulcer needing the appropriate dressing D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? A. Necrotic tissue B. Wound drainage C. Wound circumference D. Cleansed wound

D. Cleansed wound Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

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.

D. Primary intention. 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.

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.

D. Scarring can be severe. 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.