Tissue Integrity Sherpath Questions

Match the wound bed condition to its cues. 1. Pale, soft, wrinkled 2. Beefy red, shiny, moist 3. Black, hard, dry 4. Purulent yellow

Answer: 1. macerated 2. granulated 3. necrotic 4. infected

Match the type of wound drainage to the color of fluid the nurse would observe on a patient's dressing. 1. clear and watery 2. pink to pale red 3. bright red 4. greenish, yellow

Answer: 1. serous 2. serosanguineous 3. sanguineous 4. purulent

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. 1. Patient who just had an incision eviscerate 2. Patient who is experiencing shock from a profusely bleeding wound 3. Patient with a stage 4 pressure injury

Answer: 2. 1. 3.

Which Braden Scale score range would alert the nurse that a patient is at moderate risk for pressure injury development? Record your answer as whole numbers separated by a hyphen. __

13-14 - If the patient is at moderate risk for pressure injury development, the Braden score will be 13‐14.

Using military time, at what time would the nurse turn the patient if the patient was last turned at 1 p.m.? Record your answer as a whole number.

1500 - The patient is turned every 2 hours. If the patient was turned at 1 p.m. (1300 military time), the patient would be turned at 1500.

Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with minimal drainage? A. Foam B. Alginate C. Gauze D. Transparent

Answer D: - The nurse would anticipate caring for transparent dressings, which are appropriate for wounds with minimal or no drainage.

Match the unexpected skin assessment finding to its description. 1. Blue Skin 2. Pinpoint, flat, red spots 3. Red skin 4. Bruise

Answer: 1. cyanosis 2. petechiae 3. erythema 4. ecchymosis

Which term would the nurse use to describe excessive moisture on the patient's skin? A. Diaphoresis B. Ashen C. Purpura D. Icterus

Answer: A

Which interpretation would the nurse make about a patient's wound culture that is positive? A. It is infected. B. It is hemorrhaging. C. It is eviscerated. D. It is nonhealing.

Answer: A - A positive wound culture indicates the patient's wound is infected.

Which patient is likely at risk for developing a pressure injury? A. Patient with unrelieved pressure who has a fractured hip B. Patient with a history of sports-related injuries and concussions C. Left-handed patient with a broken left wrist D. Paralyzed patient who is being turned and repositioned every 2 hours

Answer: A - The patient with unrelieved pressure is most at risk for developing a pressure injury, because tissue ischemia can form and lead to pressure injuries.

Which action by the nurse is priority when providing discharge teaching to a patient and spouse about wound care when the spouse is the primary caregiver? A. Provide written instructions B. Have the patient perform a return demonstration. C. Offer strategies on how to promote wound healing D. Determine the patient's coping abilities.

Answer: A - The priority is to provide written instructions for the spouse because the spouse is the primary caregiver and will need reinforcement of learning at home.

Which hypothesis would the nurse develop for an immobile patient who has intact skin? A. Risk for Impaired Skin Integrity B. Traumatic Wound C. Risk for Impaired Tissue Integrity D. Pressure Ulcer/Injury

Answer: A Because the patient is immobile but still has intact skin, the hypothesis is a Risk for Impaired Skin Integrity.

Which foods would the nurse recommend for a patient with a leg wound who needs to increase vitamin A intake? A. Carrots B. Sweet Potatoes C. Strawberries D. Cheese E. Milk

Answer: A, B - Both high in vitamin A

Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage? A. Notify the primary health care provider. B. Take the patient's temperature. C. Review white blood cell count. D. Chart the expected findings. E. Apply Steri-Strips to the wound.

Answer: A, B, C - The nurse would notify the primary health care provider because the wound is infected. - The nurse would take the patient's temperature because the patient's wound is infected. - The nurse would review the patient's white blood cell count because the patient's wound is infected.

Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity? A. Bone B. Tendon C. Muscle D. Dermis E. Epidermis

Answer: A, B, C Bone, Tendon, & Muscle would all be damaged

Which steps would the nurse take to measure the dimensions of a sacral pressure injury? A. Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. B. Measure the width laterally from left to right at the widest portion of the wound. C. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. D. Measure the length vertically from the top to the bottom at the widest open area of the wound. E. Measure the width laterally by using a clean cotton-tipped applicator at the largest portion of the wound from left to right.

Answer: A, B, C, D

Which parameters would the nurse monitor after applying a wrap to an ankle? A. Pain B. Pallor C. Paralysis D. Petechia E. Paresthesia F. Pulelessness

Answer: A, B, C, E, F

Which cues related to skin integrity may reflect an overall health problem? A. Cracking B. Tenting C. Warm skin temperature D. Pathogens identified in a wound culture E. Immunocompetence

Answer: A, B, D

Which cues would the nurse observe for a patient with an infected lateral malleolus wound? A. Erythema noted on the superior portion of the wound B. Purulent, malodorous drainage C. 1.5-cm wound with serous drainage and tissue epithelialization D. Temperature of 102°F (38.9°C) E. Pain level of 2/10

Answer: A, B, D

Which factors may impact the development of pressure injuries or nonhealing wounds? A. smoking B. Diabetes C. Specific gender D. Urinary Incontinence E. Skin tone

Answer: A, B, D

Which patient situations are of immediate concern? A. A patient is experiencing shock. B. A patient is profusely bleeding from a wound. C. A patient has an infected wound. D. A patient has an eviscerated wound. E. A patient has a stage 4 pressure injury.

Answer: A, B, D

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum? A. Wound, ostomy, and continence nurse (WOCN) B. Social Work C. Surgeon D. Nutritionist E. X-Ray Technician

Answer: A, B, D - A WOCN would be consulted in this situation to ensure proper healing of the pressure injury. -A social worker would be part of the collaboration team in this situation to ensure the homeless patient has access to community resources and finances. -A nutritionist should be consulted because the patient is thin.

Which techniques would the nurse use to troubleshoot issues with patients' dressings? A. Use an abdominal binder to help a patient who has an abdominal wound to cough. B. Use Montgomery straps for a patient who needs frequent dressing changes. C. Use hydrogen peroxide to remove residue left on the patient's skin from a dressing. D. Use a splint to help a patient who has an abdominal incision to deep breathe. E. Use acetone to help remove a dressing stuck to the patient's skin.

Answer: A, B, D - An abdominal binder helps secure dressings and drains and provides support when coughing and would be implemented by the nurse. - Montgomery straps are used for frequent dressing changes to protect the skin from irritation and skin tears; the straps would be used by the nurse. - A splint helps provide support to a patient's incision when deep breathing; it would be used by the nurse.

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity? A. Low prealbumin levels B. Immobility C. Inexperience with wound care D. Stage 2 pressure injury E. Stage 4 pressure injury

Answer: A, B, D -Low prealbumin level is a cue for Impaired Skin Integrity because it can affect healing. -Immobility is a cue for Impaired Skin Integrity because it can lead to prolonged pressure. -A stage 2 pressure injury is a cue for Impaired Skin Integrity because it affects the epidermal and dermal layers of the skin.

Which factors can place a patient at risk for a pale, dry wound? A. anemia B. Diabetes C. wound infection D. vascular disease E. Nutritional deficiencies

Answer: A, B, D, E

For which patient hypotheses would the nurse select turning and positioning as a solution? A. impaired Skin Integrity B. Risk for Pressure Ulcer/Injury C. Malignant Wound D. Impaired Tissue Integrity E. Risk for Impaired Skin Integrity

Answer: A, B, D, E - All solutions for Impaired Skin Integrity.

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days? A. Therapies consistent with guidelines for treatment of wounds B. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) C. Ability of the patient to maintain a pain rating of 8/10 during activities of daily living D. Agreement of the patient with the treatment plan E. Capability of the patient to purchase supplies for home care as required

Answer: A, B, D, E - Therapies consistent with guidelines for treatment of wounds and pressure injuries are an appropriate component to include. - Recommendations from collaborating health care professionals, such as a WOCN, are appropriate components to include. - The patient should agree with the established treatment plan to encourage compliance, and this agreement would be included. - Capability of the patient to purchase supplies for home care is an appropriate component of care to include.

Which actions would the nurse take for a comatose patient who has frequent liquid stools and has a Braden Scale score of 8? A. Turn the patient every 2 hours for repositioning. B. Apply cold compresses to bony prominences. C. Pad and protect any bony prominences. D. Wash and dry the patient's skin after each liquid stool. E. Apply an abdominal binder for support. F. Replace soiled linens.

Answer: A, C, D, F - Turning and repositioning the patient from side to side helps prevent pressure on the skin, so the nurse would implement this action. - Padding and protecting any bony prominences help avoid pressure on the skin; the nurse would pad and protect bony prominences to avoid pressure injuries. - Washing and drying the patient's skin helps keep the skin clean and dry, so the nurse would implement these actions. Moisture and body fluids irritate the skin and cause excoriation. - Replacing soiled linens helps keep the skin clean and dry; thus, the nurse would implement this action. Prolonged contact with moisture and enzymes can lead to excoriation and maceration.

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound? A. Repositioning the patient B. Administering medication for wound pain C. Assessing and evaluating a patient's skin and wounds D. Reporting any changes in patient's skin integrity or condition. E. Applying a nonsterile dressing for chronic wounds with an established treatment plan

Answer: A, D, E -Repositioning the patient is a task the UAP can perform for a patient with a wound. -The UAP can report any changes in the patient's skin condition or integrity to the nurse. -Applying a nonsterile dressing for chronic wounds with an established treatment plan

Which evaluative cue would alert the nurse that a patient with a pressure injury is declining? A. Wound diameter was 5 cm but is now 4 cm. B. Braden Scale score was a 9 but is now an 8. C. Transfer assistance was with two people but is now with one person. D. Dietary consumption was 50% but is now 75%.

Answer: B - A Braden Scale score that decreases indicates the patient is declining. The lower the score, the higher the risk for pressure injuries.

Which reasoning explains why a nurse measures wound size during an initial wound assessment? A. To determine the proper medication amount for the wound B. To help assess progression of wound healing C. To provide evidence for the presence of infection D. To reassure patients they are receiving proper care

Answer: B - Measuring wound size helps assess the progression of wound healing. As the wound heals, it becomes smaller.

Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of wound drainage? A. Gel B. Foam C. Transparent D. Hydrocolloid

Answer: B - The nurse would anticipate using a foam dressing. It is indicated for moderately to highly exudative wounds because it pulls fluid away from the wound while maintaining a moist environment.

Which action would the nurse take when placing noncommercial ice packs on a patient's injured shoulder? A. Position the pack directly on the shoulder. B. Remove air from the pack before closing. C. Fill the pack completely with crushed ice. D. Leave the pack in place for 45 minutes.

Answer: B - The nurse would remove the air from the pack before closing.

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident? A. Patient's pressure injury will decrease at least 1 to 2 cm in size per week. B. Patient's wound will exhibit granulation tissue in the wound by 1 week. C. Patient will demonstrate wound care after receiving teaching. D. Patient will have intact skin throughout hospital stay.

Answer: B A break in the skin from external forces, such as trauma or an accident, indicates a wound; thus, this goal would directly relate to the break in skin from external forces.

Which action for skin hygiene would the nurse take for an obese patient who is immobile? A. Bathe using hot water B. Use antibacterial soap. C. Apply moisture barrier to buttocks. D. Keep skinfolds dry from perspiration.

Answer: D - The nurse would keep the skinfolds dry. In an obese patient the skinfolds must be kept dry from perspiration to prevent skin breakdown.

Which action would the nurse take when caring for a patient's Jackson-Pratt drain? A. Clean toward the drain, inward. B. Reactivate the drain after emptying. C. Wipe the port with acetone wipes. D. Allow the drain to work by gravity.

Answer: B - The nurse would reactivate the drain after emptying. The Jackson-Pratt drain works by suction and must be reactivated or recompressed after emptying.

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound? A. Patient will be infection-free. B. Patient will eat a high-protein diet at every meal. C. Patient will help with transfers within 24 hours. D. Patient's wound will heal normally. E. Patient's incision will have proper healing.

Answer: B, C A SMART outcome is specific, measurable, achievable, and relevant (high-protein diet). It also must have a time frame (at every meal).

Which patient situations would prompt the nurse to question a prescription for heat therapy? A. A patient with morning stiffness B. A patient with a local tooth abscess C. A patient with possible appendicitis D. A patient with bleeding from a small wound E. A patient with edema in the left arm

Answer: B, C, D - The nurse would question this prescription. Heat therapy is not used with abscesses, as it may cause the abscess to rupture. - The nurse would question this prescription. Heat therapy is not used with possible appendicitis, as it may cause the appendix to rupture. - The nurse would question this prescription. Heat therapy is not used with active bleeding, as it increases bleeding.

Which statements by the nurse caring for a postoperative patient who suffered a spinal cord injury indicate correct understanding about assessment tools? A. "I can use the Braden Scale to assess for the risk for infection." B. "The Norton Scale is used to assess for pressure injury risk." C. "I can use the Braden Scale to assess my patient's surgical incision." D. "When assessing for open wounds, I can use the Wound Characteristic Instrument." E. "The Pressure Ulcer Scale for Healing tool is used to track wound healing."

Answer: B, D - The Norton Scale is a tool used to assess risk for developing pressure injuries, and it indicates a correct understanding about assessment tools. - Wound Characteristic Instrument is a tool used to assess open wounds and to track wound healing.

Which actions would the nurse take for a patient receiving heat therapy? A. Allow a patient who must remain flat to take a sitz bath. B. Obtain distilled water for aquathermia treatments. C. Permit the patient to lie on the heating device. D. Check on the disoriented patient more frequently. E. Cover the container and hand when providing warm hand soaks. F. Warm the compress in the microwave.

Answer: B, D, E - The nurse would obtain distilled water for aquathermia treatments because this is the recommended action. - The nurse must check on disoriented patients more frequently because disoriented patients cannot report changes. - The nurse would cover the container and hand to help maintain the temperature of the solution.

Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)? A. Replace dressing every 5 days. B. Monitor for granulation tissue in the wound. C. Angle the canister at least 45 degrees or more. D. Avoid using NPWT for a patient with a cancerous wound. E. If the patient reports pain, change from the black foam to white foam. F. Report to the health care provider if there is an increase in wound drainage.

Answer: B, D, E, F

Which type of fluid would the nurse likely observe if the patient was hemorrhaging? A. serous B. Serosanguineous C. Sanguineous D. Purulent

Answer: C - Sanguineous fluid is bright red, and it indicates bleeding that is observed in hemorrhaging.

Which action would the nurse take for a mother who calls the clinic reporting that a thick yellowish drainage is leaking out of her daughter's surgical leg incision and the incision edges are red and warm? A. Instruct the patient's mother to change the bandage more frequently. B. Suggest the patient elevate her leg and apply an ice bag to the affected area. C. Ask the mother to bring her daughter to the office to be evaluated by the surgeon immediately. D. Suggest that the mother check her daughter's temperature every 4 hours for the rest of the day.

Answer: C - Suggesting that the patient come into the office to be evaluated by the surgeon immediately is the action to take because the scenario indicates the wound is likely infected.

Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement? A. Sharp B. Biologic C. Autolytic D. Mechanical

Answer: C - The nurse is monitoring autolytic debridement, the slowest type of wound debridement, in which the body uses its own enzymes and phagocytic cells for healing.

After receiving report, the nurse would delegate which tasks to the unlicensed assistive personnel? A. Irrigating an arm wound on a stable patient B. Setting up the negative-pressure wound therapy for a patient with a wound C. Turning a patient with a pressure injury D. Teaching the patient about cold pack use at home E. Cleaning an incontinent patient of stool and urine

Answer: C, E

Which assessment technique indicates the nurse properly determined if the patient's incision is healing or is becoming infected? A. Asking the patient health history questions B. Charting the incision line's color and tenderness C. Removing all sutures and/or staples around the wound D. Palpating the area of induration around the incision line

Answer: D - Palpating the area of induration is an effective way to assess if an incision is healing or becoming infected; an infected incision will have induration (hardness) around the incision.

Which action would the nurse take when irrigating a patient's abdominal wound? A. Cool the irrigation fluid. B. Obtain a bulb syringe C. Gently rub the area dry. D. Use sterile technique

Answer: D - The nurse would use sterile technique to irrigate a wound to decrease the chance of infection.

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat? A. Ingest 25% of each meal during hospitalization. B. Report that pain management regimen lowers pain level to 6/10 or lower within the shift. C. Show acceptance of the change in body image by continuing to have the nurse change the dressing after 1. week. D. Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

Answer: D Because the overall outcome is healing of the wound, this outcome demonstrates progressive healing of wound.

Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound? A. "My participation is not needed for position changes." B. "I will be infection-free by the time I go home." C. "I will need to meet with the mental health professional before discharge." D. "My wound will look beefy red within 1 week."

Answer: D If the wound looks beefy red within 1 week, that indicates granulation tissue is forming and the wound is healing, which is normal. This statement indicates successful teaching.