Skin Integrity and Wound Healing

Question 15. What nursing goal should be implemented when a nurse notices eschar on a client's heel? 1. Debride the wound. 2. Cleanse and protect the area. 3. Promote epithelialization. 4. Promote remodeling.

1 Option 1: The priority nursing goal should be to debride the wound first to remove necrotic tissue. Option 2: Cleansing and protecting the area is not a priority when working with necrotic tissue. Option 3: Promoting epithelialization is not the proper goal when working with necrotic tissue. Option 4: Remodeling is not an issue at this stage and thus not a priority goal.

Question 14. A client has been brought in from a motorcycle accident in which he or she has suffered deep track-like injuries with debris that can only partially be removed. What type of dressing should be applied to this client's wounds? 1. Alginate 2. Absorbent 3. Antimicrobial 4. Collagen

1 Option 1: Alginates facilitate autolytic debridement and are ideal for wounds that are deep, track-like, or tunnel-like. Option 2: Absorbent dressings are used to manage drainage. Option 3: Antimicrobial dressings should be reserved for wounds that contain exudate and are infected. Option 4: Collagen dressings are used when promotion of collagen fibers and granulation is needed.

Question 11. What should the nurse monitor in a client who is taking blood pressure medication? 1. Ischemia 2. Inhibited wound healing 3. Hematoma 4. Xerosis

1 Option 1: Antihypertensives decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Option 2: Anti-inflammatory medications such as naproxen or ibuprofen can inhibit wound healing. Option 3: Anticoagulants such as heparin and Coumadin can lead to extravasation of blood into subcutaneous tissue, which can result in a hematoma. Option 4: Certain herbal products such as lavender and tea tree oil can have a drying effect on the skin.

Question 9. A client reports to the nurse that there is drainage leaking around the Jackson-Pratt (JP) drain. The nurse notices the JP drain bulb is empty and the dressing is saturated with serosanguineous drainage. What should the nurse do first? 1. Check the JP drain tubing for kinks. 2. Compress the bulb and close the lid. 3. Remove the JP drain from the abdomen. 4. Notify the primary health-care provider.

1 Option 1: As there is no drainage in the JP bulb, but all around the dressing, there is an occlusion somewhere. The nurse's first intervention should be to check the JP drain tubing for kinks. Option 2: The nurse would compress the bulb and close the lid after emptying the drain. The JP drain is empty and leaking around the insertion site. Therefore, the nurse would not compress the bulb and close the lid. Option 3: The nurse would only remove the JP drain from the abdomen after receiving orders from the health-care provider. Option 4: The nurse would notify the primary health-care provider only if other measures are unsuccessful to resolve the problem.

Question 13. What skin integrity issue should the nurse be aware of when working with a client diagnosed with Alzheimer's disease? 1. Impaired cognition can lead to pressure injuries. 2. Alzheimer's clients are at a higher risk for falls. 3. Most clients with Alzheimer's are older and have xerosis. 4. Impaired cognition may interfere with communication.

1 Option 1: Clients with cognitive disorders may not be aware of the need to reposition and thus are predisposed to increased pressure injuries. Option 2: Some clients with cognition disorders may be at a high risk for falls, but this is not a primary issue of skin integrity. Option 3: Xerosis is an issue with older adults, but not particular to cognition issues. Option 4: Impaired communication may be a problem with Alzheimer's clients, but it is not particular to skin integrity issues unless the clients are unable to communicate discomfort.

Question 18. While reviewing a client's lab work, a nurse notices blood serum levels are low. For what potential risk should the nurse monitor? 1. Pressure injuries 2. Infection 3. Inflammation 4. Altered coagulation

1 Option 1: Delayed wound healing and pressure injuries are seen in clients with low blood serum levels that indicate limited nutritional stores. Option 2: Elevated WBCs are typically seen when infection is present. Option 3: Both ESR and WBCs will be altered when inflammation is present, but not typically in pressure injuries. Option 4: Prothrombin time is altered when altered coagulation is seen and is due to anticoagulant medications, trauma, concurrent illness, or reaction to transfusion.

Question 9. The nurse is documenting a wound after changing the dressing. Which term would the nurse include to describe black tissue noted in the wound bed? 1. Eschar 2. Slough 3. Epithelial 4. Granulating

1 Option 1: Eschar is black, dry, and leathery. This would be the term the nurse uses. Option 2: Slough is tan and stringy and is stuck in the wound bed. It is not black. Option 3: Epithelial tissue is pink or pearly white tissue noted in the wound bed that reflects regenerating epidermis. Option 4: Granulating tissue is pink to red tissue that consists of blood vessels, connective tissue, and fibroblasts.

Question 13. When checking on a postoperative client, the nurse notices evisceration. What should immediately be done? 1. Cover the wound with sterile towels or dressings soaked in sterile saline solution. 2. Have the client stay in bed with knees bent to minimize strain on the incision. 3. Notify the surgeon. 4. Prepare the client for surgery.

1 Option 1: Immediately covering the wound prevents the organs from drying out and becoming contaminated with environmental bacteria. Option 2: The client should remain in bed with knees bent, but this is not the priority. Option 3: The surgeon should be notified once the client is stabilized. Option 4: The client will need to be prepped for surgery, but this is not the immediate need that should be addressed.

Question 19. A client would like to lie directly on a heating pad for comfort. Why is this not a suggested practice? 1. A client could be burned. 2. Blood pressure will become elevated. 3. There is increased risk for maceration. 4. Prolonged heat will cause necrosis.

1 Option 1: It is more difficult to regulate both local and systemic temperature when a client lies on the heating pad directly, which increases the risk for local burns. Option 2: Blood pressure may change in some clients, but this is not the primary reason for not allowing a client to lie directly on the heating pad. Option 3: Maceration occurs when the skin is moist; therefore, unless the client is sweating profusely, it will typically not lead to maceration. Option 4: Prolonged heat is not typically a cause of necrosis.

Question 15. What is an appropriate nursing intervention to prevent dehiscence in an obese client who is recovering from abdominal surgery? 1. Maintain bedrest with the head of the bed elevated at 20° and the knees flexed. 2. Identify the risk for impaired tissue integrity. 3. The wound will heal by May 1, as evidenced by a progressive decrease in the size of the wound. 4. Provide client education on wound care.

1 Option 1: Maintaining bedrest with elevation and knee flexion is an appropriate intervention that will help reduce the risk of dehiscence. Option 2: Risk for impaired tissue integrity would be a nursing diagnosis. Option 3: Stating a time frame for wound healing would be an outcome or goal statement. Option 4: Providing client education is a nursing activity/intervention but not the best option for preventing dehiscence in this client.

Question 7. The nurse is providing frequent dressing changes to an abdominal wound due to large amounts of drainage. The repeated use of tape is irritating the skin. Which intervention would be the best option for the nurse to use to alleviate the problem? 1. Apply Montgomery straps. 2. Leave the wound open to air. 3. Decrease the dressing change frequency. 4. Change to a different brand of adhesive tape.

1 Option 1: Montgomery straps can be used to hold the dressing in place. It does not require frequent removal of tape and is less irritating to the skin. Option 2: The nurse would not leave the wound open to air. This can increase the risk for pathogens to enter the wound and cause infections. Option 3: The wound requires frequent dressing changes due to drainage. This should not be changed, as excess drainage can cause tissue maceration. Option 4: Even if the nurse changes to a different brand of tape, it still requires frequent changes and can cause tape burns.

Question 10. The nurse on the medical-surgical unit has noticed a client has edema. Why should the nurse address this issue in the care plan? 1. Poor oxygen diffusion to the cells can cause skin breakdown. 2. Wound healing is inhibited. 3. Pressure-related injuries occur due to loss of padding. 4. Diminished tactile sensation occurs.

1 Option 1: Reduced elasticity due to edema interferes with oxygen diffusion to the cells, which can result in skin breakdown and integrity issues. Option 2: Optimal wound healing is correlated with appropriate cholesterol levels, and a reduction in levels predispose clients to skin breakdown and inhibits wound healing. Option 3: Malnutrition that is prolonged causes loss of subcutaneous tissue and muscle tissue, which results in loss of padding between skin and bone and leads to pressure injuries. Option 4: Clients who have chronic diseases such as peripheral vascular disease, diabetes, trauma, and stroke often experience diminished tactile sensation resulting in skin integrity issues.

Question 9. What is the primary purpose of swaddling a newborn for the first few weeks of life? 1. Thermoregulation 2. Sense of security 3. Prevent accidental scratching 4. Mimics the womb

1 Option 1: Skin of a newborn is thinner and thermoregulation must be facilitated by swaddling and keeping the newborn's body heat contained. Option 2: While swaddling does provide comfort and a sense of security, it is not the primary purpose of swaddling. Option 3: Swaddling does limit the infant's mobility and ability to accidently scratch himself or herself, but this is not a primary purpose of swaddling. Option 4: Infants need to maintain a regular body temperature, but not necessarily the womb environment.

Question 20. What is missing from the documentation regarding the emptying of drainage from a wound? 03/12/20160750Hemovac drained serosangiuneous fluid over 12 hours. No odor or purulent material noted at drainage site...........................N. Signature RN 1. Amount drained 2. a.m. or p.m. 3. Description of color of drainage site 4. Materials used

1 Option 1: The amount drained should be noted with a description of the type of fluid. Option 2: The nurse has used standard military time, so it does not require a.m. or p.m. Option 3: The color of the drainage site is not pertinent when the drainage has been described. Option 4: The materials used is not needed in documentation regarding wound drainage.

Question 5. Which client is at highest risk for wound dehiscence? 1. A 55-year-old obese female who underwent an abdominal hysterectomy 2. A 75-year-old thin male who underwent a total hip replacement after a fall 3. A 20-year-old thin female who underwent an emergency appendectomy 4. A 40-year-old obese male who underwent back surgery for a herniated disk

1 Option 1: This client is obese and underwent abdominal surgery, which places her at high risk for wound dehiscence. Option 2: The client has a risk for infection and decreased mobility but does not have risk factors for wound dehiscence. Option 3: This client is young and has no risk factors for wound dehiscence. Option 4: The client is at low risk for wound dehiscence, as the client had back surgery, but he is not at the highest risk.

Question 17. What type of chronic wound is found typically in the lower extremities and manifests as a shallow wound with irregular wound margins and a wound bed that appears "ruddy" or "beefy" red and granular? 1. Venous stasis ulcer 2. Arterial ulcer 3. Pressure injury 4. Diabetic foot ulcer

1 Option 1: Venous stasis ulcers are caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function and are typically seen around the ankles and lower calf. Option 2: While common in the lower extremities, arterial ulcers appear "punched out," small and round with smooth borders. Option 3: A pressure injury tends to be located over bony prominences and can result in serious tissue damage. Option 4: Diabetic foot ulcers are typically located on the plantar surfaces and toes.

Question 18. What type of chronic wound is found typically in the lower extremities and manifests as a shallow wound with irregular wound margins and a wound bed that appears "ruddy" or "beefy" red and granular? 1. Venous stasis ulcer 2. Arterial ulcer 3. Pressure injury 4. Diabetic foot ulcer

1 Option 1: Venous stasis ulcers are caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function and are typically seen around the ankles and lower calf. Option 2: While common in the lower extremities, arterial ulcers appear "punched out," small and round with smooth borders. Option 3: A pressure injury tends to be located over bony prominences and can result in serious tissue damage. Option 4: Diabetic foot ulcers are typically located on the plantar surfaces and toes.

Question 13. The nurse is monitoring a wound for healing. At which stage of healing would dehiscence typically be seen? 1. Inflammatory phase 2. Maturation phase 3. Proliferative phase 4. Tertiary phase

1 Option 1: Wound dehiscence is most likely to occur during the inflammatory phase, before collagen has been deposited. Option 2: Tensile strength is increased in the maturation phase, so the skin would typically not be prone to dehiscence during this stage. Option 3: Collagen is formed during the proliferative phase, which adds strength to the wound. Option 4: Tertiary intentional healing is a method of wound healing, not a stage.

Question 14. The nurse is monitoring a wound for healing. At which stage of healing would dehiscence typically be seen? 1. Inflammatory phase 2. Maturation phase 3. Proliferative phase 4. Tertiary phase

1 Option 1: Wound dehiscence is most likely to occur during the inflammatory phase, before collagen has been deposited. Option 2: Tensile strength is increased in the maturation phase, so the skin would typically not be prone to dehiscence during this stage. Option 3: Collagen is formed during the proliferative phase, which adds strength to the wound. Option 4: Tertiary intentional healing is a method of wound healing, not a stage.

Question 12. A client has a wound that has been allowed to heal through secondary intention due to excessive loss of tissue. The physician is planning to suture the tissue together when the wound is ready. What should the nurse be monitoring to determine the readiness for delayed primary closure? 1. No evidence of edema, infection, or foreign matter 2. Small pearl-like or pink areas beginning to appear 3. Epithelial and dermal cells forming new skin 4. Platelets and fibroblasts migrating into the wound

1 Option 1: Wounds may be closed when there is no evidence of infection, edema, or foreign matter. Option 2: Epithelial tissue may appear in the wound as small pink or pearl-like areas during secondary intentional healing. Option 3: Epithelial and dermal cells form new skin in the regenerative stage of healing. Option 4: All wounds heal through a process that involves platelets and fibroblasts migrating into the wound.

Question 10. What is one skin integrity issue that should be addressed with an older adult client that has been admitted? 1. Xerosis 2. Overactive sweat glands 3. Adult acne 4. Decreased fat deposit

1 Option 1: Xerosis is itchy, red, dry, scaly, cracked, or fissured skin that is a problem for about 85% of older adults and can be a threat to the integrity of the skin. Option 2: Sweat glands typically reduce production in the aging adult. Option 3: Adult acne is typically not an issue in most adults. Option 4: Decreased fat deposit is an issue with the aging process that contributes to other more serious issues that should be addressed.

Question 11. What are primary causes of maceration? Select all that apply. 1. Fever 2. Incontinence 3. Bowel incontinence 4. Infection 5. Tanning

1,2 Option 1: Fever causes sweating and is one of the most common causes of excessive moisture on the skin leading to maceration. Option 2: Incontinence is a primary cause of maceration, which can cause moisture associated skin integrity issues. Option 3: Bowel incontinence is a primary cause of excoriation, not maceration. Option 4: Skin infection causes the skin to be more vulnerable to breakdown and hinders wound healing. Option 5: Tanning exposes the skin to damaging rays, which can lead to cancer and dry skin.

Question 5. Which lifestyle choices can lead to alterations in skin integrity? Select all that apply. 1. Smoking 2. Tanning 3. Exercise 4. Daily bathing 5. Adequate nutrition

1,2 Option 1: Smoking impairs circulation because it decreases the oxygen available for the tissues. Impaired circulation can cause skin breakdown. Option 2: Tanning exposes the skin to ultraviolet radiation, which can lead to skin cancer and changes in skin integrity. Option 3: Exercise improves circulation and does not cause skin breakdown. Option 4: Too frequent bathing can cause skin drying and infrequent bathing can cause skin infections; however, daily bathing removes soil and microbes and prevents skin breakdown. Option 5: Adequate nutrition provides nutrients to the tissues and does not lead to alterations in skin integrity.

Question 6. Which findings would the nurse expect to find when performing wound care for a client with a venous stasis ulcer? Select all that apply. 1. Irregular wound edges 2. Wound bed beefy red 3. Periwound area reddened 4. Pain noted with ambulation 5. Loss of hair to the periwound area

1,2,3 Option 1: Venous stasis ulcers have irregular wound edges. Option 2: The wound bed of a venous stasis ulcer is usually beefy red or ruddy in color. Option 3: The area around the periwound skin is reddened or edematous. Option 4: An arterial wound, not a venous stasis ulcer, produces pain upon ambulation. Option 5: Due to diminished arterial blood supply, an arterial ulcer causes loss of hair to the periwound area.

Question 6. Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of a client? Select all that apply. 1. Location of the wound 2. Length, width, and depth 3. Nutritional status of the client 4. Presence of undermining or tunneling 5. Number and type of dressing supplies used 6. Drainage amount, color, consistency, and odor

1,2,4,6 Option 1: It is essential to document the location of the wound in the medical record. This communicates information to the next nurse to provide continuity of care. Option 2: The nurse should measure wounds a minimum of once per week to determine wound progress. Option 3: The nutritional status of the client is important regarding wound healing; however, it is not a wound characteristic. Option 4: The nurse would need to document the presence of undermining or tunneling in the wound bed. Option 5: The nurse would include dressing supplies used; however, this does not describe the wound itself. Option 6: The nurse should document the color, consistency, amount, and odor of the drainage.

Question 4. The nurse is assessing the skin of a client and notes the area around the buttocks is reddened and macerated. Which factors may have contributed to this finding? Select all that apply. 1. Fever 2. Nausea and vomiting 3. Urinary incontinence 4. Shearing and friction 5. Continuous pressure

1,3 Option 1: A client with a fever is sweating and producing excess moisture that leads to skin maceration. Option 2: Nausea and vomiting does not produce excess moisture to the skin, nor does it cause skin maceration. Option 3: Urinary incontinence is moisture that can cause skin moisture. This contributes to maceration. Option 4: Shearing and friction can cause skin breakdown; however, it does not contribute to moisture. Option 5: Continuous pressure places a client at risk for pressure ulcers. This does not cause tissue maceration.

Question 10. A client presents to the emergency room after sustaining an injury where a nail entered the hand. Which questions should the nurse ask the client to determine if a tetanus shot is needed? Select all that apply. 1. "Do you have any allergies to tetanus toxin?" 2. "Have you had a tetanus shot in the past 2 years?" 3. "Was the nail rusty or was it brand new out of the box?" 4. "Have you sustained a puncture wound like this before?" 5. "Can you tell me your current pain level on a scale of 1 to 10?"

1,3 Option 1: If the client has allergies to the tetanus toxin, the vaccine would be contraindicated. Option 2: The nurse would ask the client if he or she has had a tetanus shot within the past 10 years, not 2 years. Option 3: The cleanliness of the nail will help determine if the client needs a tetanus shot. Therefore, the nurse would ask this of the client. Option 4: It is not necessary to determine if the client has sustained a puncture wound before. Option 5: The nurse would assess the client's pain level in order to provide pain relief; however, it is not related to administering the tetanus vaccine.

Question 3. A client with peripheral arterial disease presents to the clinic with an open wound to the left shin. Which clinical manifestations would the nurse expect to find during the assessment? Select all that apply. 1. Pain 2. Edema 3. Loss of hair 4. Tissue necrosis 5. Jagged wound edges

1,3,4 Option 1: Pain is the primary manifestation that differentiates an arterial ulcer from a venous ulcer. The nurse would expect the client to report pain. Option 2: Edema is a clinical manifestation found in venous stasis ulcers, not arterial ulcers. Option 3: Hair loss occurs from decreased oxygenation to the area. Option 4: Tissue necrosis occurs from impaired oxygenation from peripheral arterial disease. Option 5: Venous stasis ulcers cause a wound with jagged edges; this does not occur with an arterial ulcer.

Question 12. Which nursing interventions are most appropriate for a client with urinary incontinence to prevent skin breakdown? Select all that apply. 1. Apply barrier moisture cream. 2. Elevate the head of the bed 45°. 3. Provide skin care after every incontinent episode. 4. Use absorbent products that wick moisture away from skin. 5. Obtain a prescription for an indwelling urinary catheter insertion.

1,3,4 Option 1: The nurse should ensure that barrier moisture cream is applied after each incontinence episode and with bathing. This will help prevent skin breakdown. Option 2: The head of the bed should be elevated 30° to prevent sliding in bed. Option 3: The nurse should clean the client and provide good skin care after each incontinence episode. Option 4: The goal to prevent skin breakdown is to keep the skin dry. Therefore, the nurse should use absorbent skin products that wick moisture away from the skin. Option 5: The nurse would not ask for a prescription for an indwelling urinary catheter to prevent skin breakdown. The catheter can lead to urinary tract infections.

Question 2. The nurse is educating a client with new onset type 1 diabetes mellitus regarding microvascular and macrovascular complications. Which interventions should the nurse instruct the client to include in daily care to prevent skin breakdown? Select all that apply. 1. Inspect the feet daily. 2. Soak the feet every day. 3. Dry the feet thoroughly. 4. Wear well-fitting shoes. 5. Clip the toenails every week.

1,3,4 Option 1: The nurse would instruct the client to inspect the feet every day for redness or calluses that could lead to skin breakdown. Option 2: The client should not soak the feet because this can cause skin maceration, which can cause breakdown of the skin. Option 3: The nurse would educate the client to dry his or her feet after a shower to prevent fungal infections, as this can irritate the skin and initiate skin breakdown. Option 4: The client with diabetes should wear well-fitting shoes to prevent rubbing, corns, or calluses from forming that can lead to skin breakdown. Option 5: The client with diabetes has decreased sensation in the feet due to microvascular and macrovascular complications. Therefore, the client should have foot care performed by a podiatrist.

Question 19. What lifestyle practices can cause changes to the integrity of the skin? Select all that apply. 1. Tanning 2. Exercise 3. Smoking 4. Skin cleansing 5. Body piercings

1,3,4,5 Option 1: Tanning exposes the skin to damaging UV rays that can lead to skin cancer and dryness. Option 2: Exercise increases circulation to the skin, thus promoting skin integrity and wound healing. Option 3: Smoking reduces oxygenation to the cells and tissue, leading to compromised wound healing and skin breakdown. Option 4: Excessive or insufficient cleansing can lead to skin breakdown, dryness, and bacterial overgrowth, which can lead to infection. Option 5: Complications occur in about 20% of body piercings and include local infections, sepsis, endocarditis, hepatitis, and toxic shock syndrome.

Question 1. What are the functions of the stratum corneum layer of the skin? Select all that apply. 1. Prevents water loss 2. Eliminates foreign material 3. Protects from ultraviolet light 4. Functions as a protective barrier 5. Stops chemicals from entering the body

1,4,5 Option 1: The stratum corneum prevents water from being lost from the body. Option 2: Langerhans cells are responsible for eliminating foreign material. This does not happen in the stratum corneum layer. Option 3: The melanocytes protect the skin from ultraviolet light exposure. This is not a function of the stratum corneum. Option 4: The stratum corneum functions as a protective layer. Option 5: The stratum corneum stops chemicals from entering the body.

Question 6. The nurse is assessing a client's risk for skin breakdown using the Braden scale. The nurse notes: The client is alert and oriented to person and is able to answer commands. The client has skin that is occasionally moist due to urinary incontinence. The client stays in the chair most of the day, needs assistance to get up. The client is unable to reposition on his or her own and frequently needs to be pulled up in bed. The client eats about 50% of breakfast and dinner but frequently skips lunch. What would the nurse rate as the client's Braden score?

14 Correct Feedback According to the Braden scale, the client would receive 3 points for being able to answer commands, 3 points for occasional moisture, 2 points for being chairfast, 2 points for limited mobility, 3 points for adequate nutrition, and 1 point for frequently sliding down in bed. This equals 14 points.

Question 4. The nurse is working with a client with low total protein and serum albumin levels. The client presents with bilateral pitting lower extremity edema. Which education should the nurse provide to decrease and prevent edema formation? 1. Increase cholesterol in the diet. 2. Increase protein foods in the diet. 3. Increase vitamin C and zinc content. 4. Increase fluid intake during the day.

2 Option 1: Clients with low cholesterol levels are at a higher risk for skin breakdown. This can inhibit wound healing, but it does not affect edema. Option 2: Edema forms from changes in oncotic pressure. When albumin is deficient, fluid leaks out of the capillaries into the interstitial spaces, causing edema and skin breakdown. If the client increases protein in the diet, it should draw fluid back into the vascular compartment and decrease edema. Option 3: If the client develops a wound, the nurse would instruct the client to increase vitamin C, zinc, and copper in the diet. These do not cause edema to form. Option 4: The nurse would educate a client who is dehydrated to increase fluid intake. A client with edema has too much fluid and adding more through intake would worsen edema.

Question 6. The nurse is documenting wound progress for a client and notes that there is pearly pink tissue in the wound bed as well as granulation tissue. It has decreased in size over the past 4 weeks. Which type of healing should the nurse document is occurring? 1. Primary intention 2. Secondary intention 3. Tertiary intention 4. Inflammatory phase

2 Option 1: Primary intention healing occurs when the edges are well approximated and heals with minimal scarring. A surgical incision would be healing with primary intention. Option 2: This wound is healing by secondary intention, as there is granulation and epithelial tissue in the wound bed. The wound is healing from the inside out. Option 3: An example of wound healing by tertiary intention would occur after secondary intention. When a secondary intention wound heals enough, it can be surgically closed by tertiary intention. Option 4: The inflammatory phase occurs when the wound occurs and is not part of the healing process.

Question 16. Which tissue found in the wound bed is described as dry, thick, and leathery, and may be black, brown, or gray? 1. Slough 2. Eschar 3. Granulation 4. Nongranulating

2 Option 1: Slough may be white, yellow, or tan. Option 2: Eschar is dry, thick, and leathery. It may be black, brown, or gray Option 3: Granulation is made of new blood vessels, connective tissue, and fibroblasts. Option 4: A nongranulating bed is pink, shiny, and smooth.

Question 4. The nurse examines a wound on a client's hip and notes purulent drainage. The wound culture report states it has developed critical colonization. How should the nurse interpret these findings? 1. The wound culture was contaminated. 2. The bacteria have overwhelmed body defenses. 3. The microorganisms are causing harm and releasing toxins. 4. The report means there are microorganisms in the wound.

2 Option 1: The nurse would not consider the wound contaminated, as it has purulent drainage and has developed critical colonization. Option 2: Critical colonization means the wound has overwhelming bacterial presence that leads to changes in drainage, color, or odor. Option 3: An infection means the microorganisms are causing harm and releasing toxins. The client does not have an infection yet. Option 4: The presence of microorganisms in the wound does not become critically contaminated until bacteria have overwhelmed the wound.

Question 7. The nurse is supervising a student nurse who is managing the care of a client who has lower extremity edema related to an arterial skin ulcer. Which action made by the nursing student requires correction? 1. Elevating the lower extremity 2. Applying compression stockings 3. Instructing about smoking cessation 4. Administering pain medications before dressing change

2 Option 1: The nursing student should elevate the client's lower extremities to decrease the edema. Option 2: The student nurse should not apply compression stockings to the lower extremities of a client with an arterial ulcer. This will further compromise blood flow and can lead to tissue necrosis. Option 3: A client with an arterial ulcer should not smoke, as this will further limit blood supply to the area. The student nurse should educate the client regarding smoking cessation. Option 4: Arterial ulcers are painful and the client would benefit from pain medication prior to the dressing change.

Question 1. The nurse is preparing a new skin care protocol for elderly residents in a nursing home. Which factors require specialized skin care for these clients? Select all that apply. 1. Changed estrogen levels 2. Decreases in lean body mass 3. Impaired thermoregulation 4. Thinning subcutaneous tissue layer 5. Diminishing sweat and sebaceous glands

2,4,5 Option 1: Estrogen levels increase in adolescence, causing darkening of the skin, striae to form, and increased skin oiliness. Option 2: Aging causes a decrease in lean body mass, which can cause skin breakdown. Option 3: Thermoregulation is impaired in infants, not in elderly clients. Option 4: With age, the subcutaneous layer begins to thin. This places the client at risk for skin breakdown. Option 5: As clients age, sweat and sebaceous gland function diminishes, leading to skin becoming dry.

Question 3. The nurse is preparing a new skin care protocol for elderly residents in a nursing home. Which factors require specialized skin care for these clients? Select all that apply. 1. Changed estrogen levels 2. Decreases in lean body mass 3. Impaired thermoregulation 4. Thinning subcutaneous tissue layer 5. Diminishing sweat and sebaceous glands

2,4,5 Option 1: Estrogen levels increase in adolescence, causing darkening of the skin, striae to form, and increased skin oiliness. Option 2: Aging causes a decrease in lean body mass, which can cause skin breakdown. Option 3: Thermoregulation is impaired in infants, not in elderly clients. Option 4: With age, the subcutaneous layer begins to thin. This places the client at risk for skin breakdown. Option 5: As clients age, sweat and sebaceous gland function diminishes, leading to skin becoming dry.

Question 2. The nurse is caring for a client who is deficient in protein and has poor skin turgor. Which skin cells would be causing this to happen? 1. Dermis cells 2. Melanocytes 3. Keratinocytes 4. Langerhans cells

3 Option 1: Dermis cells are not affected by low protein levels; they contain sebaceous and sweat glands. Option 2: Melanocytes produce pigments that give skin its color. They are not affected by low protein levels. Option 3: Keratinocytes are protein-containing cells that give skin its strength and elasticity. If the client is protein deficient, the lack of protein in these cells affects skin turgor. Option 4: Langerhans cells phagocytize foreign cells and trigger the immune response. This function is not related to protein levels.

Question 17. A nurse notices a wound that has developed on the lower back of a client that has adipose tissue exposed with full-thickness skin loss. What stage is this pressure injury? 1. 1 2. 2 3. 3 4. 4

3 Option 1: Stage 1 involves a localized area of intact skin with nonblanchable redness typically seen over a bony prominence. Option 2: Stage 2 has open but shallow wounds with a red pink wound bed. Option 3: Stage 3 involves a deep crater characterized by full-thickness skin loss, damage or necrosis of subcutaneous tissue, and visible adipose tissue. Option 4: Stage 4 involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures.

Question 8. The nurse is educating a client on performing his or her own wound care upon discharge. The wound bed has some necrotic tissue in it. What should the nurse include in the instructions? 1. Dry it. 2. Clean it. 3. Don't scrub it. 4. Leave it open to air.

3 Option 1: The nurse would instruct the client with a moist wound to dry it out with the dressing change. This is not proper for a wound with necrotic tissue. Option 2: A wound that has contamination should be cleaned; however, this is not appropriate for a wound with necrotic tissue in the wound bed. Option 3: The nurse would instruct the client to not scrub the wound bed of a necrotic wound. Option 4: A wound with necrotic tissue in the wound bed should be covered and not open to air.

Question 12. Which level of contamination describes a wound with bacteria in excess of 100,000 organisms per gram of tissue? 1. Clean 2. Clean-contaminated 3. Contaminated 4. Infected

4 Option 1: A clean wound has minimal inflammation. Option 2: Surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts are clean-contaminated. Option 3: An open, traumatic wound is contaminated. Option 4: A wound with bacteria in excess of 100,000 organisms per gram of tissue is infected.

Question 5. A client presents to the clinic after falling in a parking lot and sustaining an injury. There is a break in the skin with jagged edges. There is no evidence of foreign debris in the wound. As the nurse documents the wound care, which term would the nurse use in the health record? 1. Abscess 2. Incision 3. Crushing 4. Laceration

4 Option 1: An abscess is a localized collection of pus. The abscess does not have jagged edges. Option 2: An incision is formed from a surgical procedure. The client fell and did not have surgery. Option 3: A crushing injury is a wound caused by force with a minimal break in the skin. This client has a wound with jagged edges; it is not a crushing injury. Option 4: A laceration is a cut in the skin when the skin and mucous membranes are torn open. It leaves a cut with jagged edges.

Question 8. The nurse is reviewing laboratory results for a 55-year-old client with a venous stasis ulcer. Which result reflects the presence of chronic wound inflammation? 1. Serum albumin level 4.0 g/dL 2. White blood cell count (WBC) 8000/mm3 3. Partial thromboplastin time (PTT) 16 seconds 4. Erythrocyte sedimentation rate (ESR) 40 mm/hour

4 Option 1: An albumin level of 4.0 g/dL is within normal limits and indicates the client has adequate nutrition. It does not reflect the presence of chronic wound inflammation. Option 2: A WBC of 8,000/mm3 is a normal finding and does not indicate the presence of chronic wound inflammation. Option 3: The PTT is normal for this client. It reflects good clotting ability. This laboratory test will not reflect the presence of infection. Option 4: An ESR of 40 mm/hour indicates the presence of inflammation. The normal range for a 55-year-old client is 0 to 20 mm/hour.

Question 14. Which phase of wound healing describes collagen fibers breaking down and remodeling? 1. Hemostasis 2. Inflammation 3. Granulation 4. Epithelialization

4 Option 1: During hemostasis, platelets aggregate to slow bleeding. Option 2: In inflammation, macrophages begin engulfing bacteria and clearing debris. Option 3: In granulation, fibroblasts migrate to the wound where they form collagen. Option 4: In epithelialization, collagen fibers are broken down and remodeled.

Question 7. The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record? 1. Serous 2. Purulent 3. Sanguineous 4. Serosanguineous

4 Option 1: Serous drainage is a clear or a straw-colored fluid; it does not contain pink or red color. Option 2: Purulent drainage is a thick pus-filled drainage that has a bad odor. Option 3: Sanguineous drainage is bloody-red drainage that results from capillary damage. There would be no pink tinge to the color. Option 4: Serosanguineous drainage is a mixture of serous and sanguineous drainage that is light red or pink-tinged.

Question 9. Place in order the steps for obtaining a sterile wound culture. 1-Label the tube with the name, time, date, and source and send to the lab. 2-Twist the top of the aerobic culturette tube to loosen the swab. 3-Gather supplies and don nonsterile gloves. 4-Place an emesis basin under the base of the wound. 5-Insert the swab into the aerobic culturette container. 6-Press the swab against a beefy red portion of the wound bed. 7-Crush the bottom of the ampule to activate the culture medium. 8-Irrigate the wound with a 35-mL syringe and 19-gauge angiocatheter.

Correct Sequence - 3,4,8,2,6,5,7,1 Correct Feedback The nurse would gather the needed supplies and don nonsterile gloves. After removing the old dressing, the nurse would place an emesis basin under the base of the wound and then irrigate the wound using a 35-mL syringe with a 19-gauge angiocatheter. This prevents too much psi that results from using a smaller syringe. The nurse would then twist the top of the aerobic culturette tube to loosen the swab and press the swab against a beefy red portion of the wound bed. The next step is to carefully insert the swab into the aerobic culturette container and then crush the bottom of the ampule to activate the culture medium. The nurse should then label the tube with the name, time, date, and source and send it to the lab.