WebWoc WND580
Mrs. Anderson has dependent rubor and elevation pallor of her right lower extremity. The systolic pressure in her R. arm is 170 mmHg; L arm is 165 mmHg, R. dorsal pedis systolic pressure was 100 mmHg and the posterior tibial pressure was 95 mmHg. What is Mrs. Anderson's ABI for the RLE?
0.59 Record the highest brachial pressure in the arms. Record the highest pressure from the dorsal pedis and posterior tibial pulse location. Calculate the ABI by dividing the higher of two ankle pressures by the higher of the two brachial pressures. 100 (highest of two ankle pressures) is divided by 170 (highest of 2 brachial pressures) = 0.588; round off to 0.59 ABI.
Ultrasonic mist aids in debridement of necrotic tissue and reduces bioburden of wounds using:
A saline mist.
Which of the following assessments is most indicative of an arterial ulcer?
An ABI of 0.7. An ABI of less than 0.9 is indication that the wound has an arterial insufficiency or LEAD (lower extremity arterial disease). Pain occurs with many types of leg ulcers as well as arterial. Many factors can contribute to the color and condition of the wound bed.
Patients undergoing myocutaneous flap closure of a pressure injury are BEST managed in the initial postoperative period on what type of support surface?
An air-fluidized bed with non-shear surface.
Review case scenarios below, which scenario is an example of a tertiary wound closure?
An open abdominal surgical wound with evidence of granulation tissue then sutured closed.
The nurse assessing the pain of a patient with chronic leg ulcers documents a moderately severe pain level of seven on a scale of one to ten. In the following list, which intervention would be the MOST appropriate adjunct to his scheduled pain medication?
An option to call a "time out" during wound related procedures.
Your wound assessment reveals a full thickness ulcer, with scant amount of serosanguinous drainage. You note that the wound base is pale pink and there is a tunnel at 3 o'clock. The wound measurements are unchanged in the last 2 week's wound assessments. The patient denies pain with palpation, but you note mild periwound erythema. What would be your BEST response in developing the plan of care for this patient?
Apply a silver hydrogel impregnated gauze strip wicked into the tunnel.
A 34-year-old female is admitted for management of pain and palliative wound care for metastatic breast cancer. During her physical exam, the wound in the left breast is a fungating mass sized at 12 cm x 10 cm x various heights with slough and scant drainage. What physiologic wound care would you recommend?
Apply hydrogel sheets to the left breast to gently debride and decrease pain.
Mr. Benn's venous ulcers have now resolved completely. You have fitted him with proper below the knee compression stockings. Your discharge instructions include which of the following?
Apply stocking upon rising in the morning.
You were called to the Cancer Center to evaluate a patient receiving daily radiation to his R. neck region. You note primarily dry desquamation with small patches of weeping skin, redness and edema. Which treatment modality would be the MOST appropriate for this patient?
Apply unscented hydrophilic creams twice daily
As you examine a patient's lower extremity you observe a thin leg with dry skin and very little hair; the ABI is 0.5. From this data, what condition would you assess to be present?
Arterial insufficiency.
Mrs. Jones has an ulcer located on the dorsal surface of the third toe on the left foot. The ulcer is 1 cm in diameter, with a dry, pale pink wound bed. She reports significant pain in the ulcer and denies any history of diabetes. What is the MOST likely cause of this ulcer?
Arterial insufficiency.
Which of the following debridement techniques is within the scope of practice of the WOC nurse and expedites the removal of a non-infective eschar covering a pressure injury?
Autolytic debridement.
Mr. Simpson has a BMI >40 and is admitted for R. side hemiplegia due to a stroke. Considering pressure redistribution needs for this bariatric patient, which of the following would be most appropriate in meeting his unique needs?
Bariatric bed with therapeutic mattress and microclimate control.
What is the primary reason for taking the time to perform a comprehensive assessment to identify protein energy malnutrition as opposed to ordering a simple blood draw to formulate a diagnosis?
Blood tests do not provide a 'stand-alone' assessment.
Of the following, which would be most appropriate as a primary dressing for an exudative pressure injury with a depth of 4.5 cm?
Calcium alginate.
What is Mrs. Lang's foot deformity called when there is a rocker bottom appearance to her foot?
Charcot's joint.
A 98-year-old has a pressure injury that is not healing. She has a low zinc level. How does the low zinc level affect her wound healing?
Collagen synthesis will be delayed.
Mr. Lee was found lying at home on the floor. Upon admission, he has an intact, nonblanchable, persistent purple discoloration over the coccyx. Which describes the classification of his pressure injury?
Deep tissue pressure injury.
Traditional negative pressure wound therapy is an appropriate option for which of the following wounds?
Dehisced abdominal incision with copious exudate and mild periwound erythema.
Mr. Best has been diagnosed with lower extremity arterial disease (LEAD). What risk factor for arterial disease may have played the greatest role in atherosclerosis development?
Diabetes mellitus.
The recombinant PDGF (platelet derived growth factor), Regranex, is specifically indicated for which of the following wounds?
Diabetic plantar ulcers.
Of the following wound care strategies, which demonstrates knowledge of physiologic wound care?
Dressing change orders at intervals recommended by the manufacturer (usually every 3-4 days) or if leaking.
What diagnostic test is considered the "Gold Standard" for diagnosing LEVD (lower extremity venous disease)?
Duplex ultrasound.
Upon your assessment of Mrs. Jones sacral pressure injury, you note a lack of reduction of size in a clean granulating wound for the last 4 weeks thus suggested the use of electrical stimulation because of the following positive effects?
Enhance perfusion and migration of cells critical for healing.
The phenomenon of "contact inhibition" is associated with:
Epithelial migration as a wound resurfaces.
Which statement accurately describes the characteristic and implication of necrotic tissue in a wound bed?
Eschar usually is black, brown or gray and associated with deeper tissue damage. It is usually firmly attached to the wound base.
A 32-year-old patient has several linear, hollowed-out, crusted lesions with the loss of epidermis on his left lower leg. In his visit documentation, you describe these lesions as a(n):
Excoriation.
Which cells located in the dermis produce collagen (dermal building blocks) and elastin (tensile strength)?
Fibroblasts.
Of the following dressings, which is best for the moderately exudative venous ulcer?
Foam dressing.
Which of the following situations is indicative of a wound infection?
Friable red wound bed, increase in exudate production, periwound erythema and odor.
Which of the following wounds will heal with scar formation?
Full thickness wound.
Which of the following statements concerning the management of a mixed venous/arterial ulcer with an ABI of .75 is TRUE?
Graduated compression can be provided at a modified level of support.
When changing a wound dressing over a full thickness wound, you notice the wound bed is shiny, moist, red and has a cobblestone appearance. What terminology would you use to document this observation?
Granulation is present.
As specialists working in wound care, it is important to involve the patient in determining the goal for the wound. Some therapies are so time-consuming and expensive that patients may not continue to be adherent to protocols. Of the following, which are examples of goals for a wound?
Healing, maintenance (delayed healing) and comfort.
Which area of the body is the MOST difficult to offload using a pressure redistribution surface?
Heel.
A patient has an acute full-thickness wound due to trauma. What order of healing would occur with this wound?
Hemostasis, inflammation, proliferation and maturation
An elderly female developed a dehisced wound following abdominal surgery for a bowel obstruction. Which of the following conditions BEST explains what placed her at risk for developing a wound dehiscence?
History of radiation in the surgical field.
Of the following dressings, which would be most appropriate for a shallow, clean, granulating wound that measures 2 cm X 1.5 cm and has minimal exudate?
Hydrocolloid dressing.
Which of the following dressings would be most appropriate for a patient with a full-thickness pressure injury with significant undermining and a dry wound bed?
Hydrogel impregnated gauze.
The wound care nurse is following the TIMERS concept to promote wound healing. Which statement accurately describes this concept based on the tissue (T) management step of the framework?
Hypergranulation tissue slows wound healing by preventing epithelialization.
You are called into a care conference to help the Skin Care Team determine a plan of care to promote bariatric skin integrity. What characteristic listed is a SIGNIFICANT risk factor for alteration in skin integrity for those diagnosed with obesity?
Increased bacterial load on skin especially in body folds
Mr. Brown has mild to moderate urinary incontinence and limited mobility. Which of the following will most likely occur due to the effects of prolonged moisture on his peri-genital skin?
Increased risk of mechanical injury.
As wound healing progresses, collagen deposition and remodeling occur and has which of the following effects?
Increased tensile strength.
The wound care nurse is monitoring the cleansing process of a necrotic wound. What technique is recommended?
Irrigate the wound with 4 to 15 psi force.
Which of the following is a benefit of moist wound healing?
It promotes autolysis.
The wound care nurse is investigating why modalities and treatments used in the management of wounds are less effective with spinal cord-injured (SCI) patients. What is one reason to consider is:
Lack of spasticity management & AD (autonomic dysreflexia) trigger identification.
A heel ulcer with a non-infected stable eschar is BEST managed by which of the following:
Leave open to air.
A patient in the outpatient wound clinic has a venous ulcer and with palpation, the skin around the ulcer feels firm and woody or hardened. This describes what condition?
Lipodermatosclerosis.
You are observing the limbs of a new patient and note that one limb has brawny non-pitting edema from the toes to groin and positive Stemmer sign while the other is without edema and no distortion in the leg shape. What type of disorder is this patient most likely suffering from?
Lymphedema.
When the skin around a wound develops a whitish appearance, it can be described as:
Macerated.
The preoperative preparation for the surgical repair of an extensive wound should include which of the following interventions to reduce or control host factors?
Maintain blood glucose of 130 mg/dl or less (or tight glycemic control).
47% of all pressure injuries occur over the ischial tuberosities and sacrum. What PRIMARY prevention intervention would the nurse institute to address ischial tuberosities based on this statistic?
Maintain the wheelchair and seat cushion in proper working order.
The wound nurse is providing discharge education to a patient who suffered a deep partial thickness burn to their lower extremity. What intervention would be most appropriate in the plan of care?
Moisturizers and OTC antihistamines.
You are aware that age itself is NOT a risk factor for failure to heal wounds. Problems in wound healing for the elderly are most likely associated with:
Multiple co-morbidities.
An ambulatory patient with insulin dependent diabetes has an ulcer located on the plantar surface of the left foot over the third metatarsal head. The ulcer is 1 cm in diameter, with a dry red surface. The patient denies any pain in the ulcer. What type of wound does this most likely represent?
Neuropathic Ulcer.
While you are educating the staff at the NICU, one of the staff members wanted your recommendations on treating a pre-mature infant's skin stripping injury. Which of the following interventions would be the BEST choice to manage the skin stripping?
Non-adherent absorptive dressing held in place with stretch netting.
Which single risk factor is MOST likely to lead to SSI (surgical site infection)?
Obesity.
Arterial disease, hypotension, vasopressors and severe anemia can be deleterious to wound healing because they decrease the amount of:
Oxygen in the tissue.
Mr. Carter is in ICU following coronary artery bypass graft surgery. He communicates that he is having significant pain. The incision on his upper right thigh is approximated and intact and covered with a transparent dressing; a slight redness is noted around the incision. Which of the following assessments place him at risk for impaired oxygen perfusion to tissues surrounding the thigh wound?
Pain.
You have a patient in acute care who has multiple risk factors for skin breakdown. Which of the following statements are true regarding frequency of skin assessment?
Patients at risk for skin break down should have at least a daily skin inspection.
You have a patient in acute care admitted for an exacerbation in their congested heart failure. Which of the following statements is true regarding frequency of skin inspection?
Patients should have at least a daily or once a shift skin inspection.
Which of the following cells plays a central role in initiating the wound repair process?
Platelets.
You have a patient with an ischial tuberosity pressure injury that is covered with 100% necrotic tissue. Prior to performing conservative sharp debridement, what factor is the least of importance in the ability to perform conservative sharp debridement?
Presence of loose, avascular tissue in the wound.
Your 80 y/o patient with diabetes is scheduled to have surgery to repair a hip fracture. What is the BEST POST-OP intervention to minimize her Surgical Site Infection (SSI) risk.
Prevent hyperglycemia.
Urinary and fecal incontinence is considered a risk factor for pressure injury development because of what factors?
Promotion of maceration and friction.
Lymphedema is the accumulation of:
Protein rich fluid in the soft tissue.
As the Wound Care Nurse Specialist, you are teaching your Skin Care Team about the importance of maintaining a physiologic wound environment. One of your nurses asks the question, "what is a physiologic environment for a wound?" Your best response would be conditions established in the wound that:
Provide the wound with adequate moisture, pH regulation, control of temperature and bioburden.
Hyperbaric oxygen treatments (HBOT) are indicated for which of the following conditions?
Radiation induced necrotic wounds.
A colleague is talking with you in the elevator about your wound care protocols and practice. The question raised is - what type of evidence do you have to validate that your practice is evidence-based? Of the following, select research that is the most evidence-based for your practice.
Randomized controlled studies, guidelines for practice from reputable wound care societies.
Which of the following treatment would be most appropriate for the management of a partial thickness wound with a fully approximated epidermal flap?
Re-approximate edges and apply a non-adherent dressing.
The nursing staff calls you because a patient suffered an extravasation of Vancomycin at a peripheral IV site, your immediate instructions are to:
Recommend topical wound therapy once residual drug is aspirated.
The 3 principles of Wound Care provide a useful format for prioritizing approaches in wound care. They are:
Reduce/eliminate the cause of the wound, support the host and maintain a physiologic environment.
The new patient admitted to the LTAC (Long-term Acute Care) has a stage 3 pressure injury with 100% granulation tissue and moderate amount of exudate. The wound edge is well defined with a rolled edge from 12 to 5 o'clock and hyperkeratotic edge from 5 to 12 o'clock. The most appropriate intervention you select for this wound is the following:
Referral to open up the edges.
The care plan for the patient with a pressure risk assessment score (Braden Scale) of 9 and on a therapeutic support surface should always include:
Reposition the patient every 2-4 hours depending upon tissue tolerance.
As you setup a skin care program, you identify the elderly to be at risk for skin tears due to the effects of aging on:
Rete ridges.
A routine baseline assessment of the lower leg in a patient with diabetes and neuropathy should include:
Sensory testing with a monofilament.
Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath. Which of the following is considered a potential PRIMARY etiologic factor in the development of a pressure injury for this patient?
Shear force
Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3 pressure injury on her coccyx with undermining. Which of the following risk factors is most responsible for undermining in the pressure injury?
Shear from having the head of bed elevated to 45 degrees.
You are providing some patient education for a patient at risk for a neuropathic foot ulcer in obtaining proper foot wear, which of the following is the MOST important factor when selecting proper foot wear?
Shoes should be sized in the afternoon to accommodate foot edema.
You are called to the neonatal intensive care unit regarding appropriate products to use on the skin of neonates. Which of the following products would be considered safe to use on the neonates skin?
Silicone.
Which of the following dressings is most appropriate to use in a pressure injury with a granulation tissue filled wound bed measuring 3cm X 5 cm X 2.5 cm with undermining that extends 4 cm from 6 to 9 o'clock? The wound has become increasingly exudative in the past 3 weeks.
Silver impregnated alginate rope.
90-year-old female in a nursing home has a partial thickness wound with a fully approximated epidermal flap on her left forearm. Identify the type of skin damage present:
Skin tear, Type 1.
One of the reasons scab formation and necrotic tissue are generally considered undesirable in the wound is because they:
Slow the process of epithelialization.
A patient with paraplegia is in the wound clinic to have a new seating surface re-evaluated. You notice a serous fluid filled blister on the left heel which you document as a pressure injury in what Stage?
Stage 2.
Which type of injury would be most appropriate to utilize a low air-loss (LAL) bed in a patient with a low Braden mobility and moisture subscale score?
Stage 3 sacral pressure injury.
You are evaluating a palliative care patient with a lower extremity arterial ulcer. What is the primary goal and treatment focus in developing a plan of care?
Symptom control and prevention of pressure injuries.
Mrs. James has an eschar covered heel ulcer and you decide that the best approach to management is NOT to debride but to keep the eschar covered, dry and intact. The rationale for your decision is that the:
TcPO2 (transcutaneous oxygen) is 15 mmHg. A TcPO2 level below 40 mmHg demonstrates skin/tissue hypoxia and is a sign for possible delayed healing. If the eschar is non-infected and dry, it is best left in place because it provides a natural barrier to outside pathogens. Infection of an ischemic leg ulcer requires aggressive systemic antibiotics and debridement of necrotic tissue. Periwound erythema may also be a sign of infection, but further data is needed. Albumin levels of 3.0 show some reduced protein stores but this is not as important of a factor in non-debridement of an eschar covered wound.
Which of the following statements about contact casting is correct?
The contact cast redistributes the weight of the diabetic foot.
A swab culture of the surface of the wound can misdiagnose a wound infection because:
The surface organisms may not represent the organisms invading the wound tissue.
A partial thickness wound is considered difficult to heal (refractory or recalcitrant) if:
There has been no improvement in 1 - 2 weeks despite appropriate treatment.
Which of the following statements about inelastic compression bandages is accurate?
They are only effective in the ambulatory patient.
Gauze is a dressing material with a high moisture vapor transmission rate (MVTR). When wounding of the skin occurs the transepidermal water loss (TEWL) rate of the skin goes up. When these two conditions exist, what is happening in the wound?
Tissue dehydrates because the TWEL is increased and a dressing material is in use that allows for additional dehydration. This situation frequently results in cell death.
Which of the following causes of massive tissue loss is most commonly associated with a severe drug reaction?
Toxic Epidermal Necrolysis (TEN).
A patient has pyoderma gangrenosum with a LE ulceration. It is acutely painful and typically breaks down to form a progressively larger ulceration with a bright red "halo" on the ulcer border. It also typically has a purple (violaceous) border and may have undermining at the wound edges, inflamed, necrotic base, boggy tissue, purulent drainage. The treatment for this problem is to:
Treat the underlying disease.
You have a preterm neonate patient with a large surgical abdominal wound draining a large amount of exudate. What will you need to consider in wound management for this age patient?
Weigh dressings and eliminate the use of adhesives.
Intermittent claudication leg pain is characterized as pain that occurs:
With activity and is relieved by rest.
Traditional Negative Pressure Wound Therapy (NPWT) is indicated for:
Wounds with 80% granulation tissue in the wound base.
Acute versus chronic wound characteristics are:
have different types of cellular activity, different levels of proteases.
Which of the following statements is TRUE? Venous dermatitis:
results in erythema, crusting, scaling skin of the leg.
