Chapter 48 Practice Questions - Skin Integrity and Wound Care

Question 1

A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?

a. Decreased level of consciousness
b. Adequate dietary intake
c. Shortness of breath
d. Muscular pain

Answer 1

a. Decreased level of consciousness

Question 2

The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development of a decubitus ulcer?

a. Resistance
b. Pressure
c. Weight
d. Stress

Answer 2

b. Pressure

Question 3

Which nursing observation will indicate the patient is at risk for pressure ulcer formation?

a. Fecal incontinence
b. Ate two thirds of breakfast
c. A raised red rash on the right shin
d. Capillary refill is less than 2 seconds

Answer 3

a. Fecal incontinence

Question 4

The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient’s medical record?

a. Stage I pressure ulcer
b. Healing Stage II pressure ulcer
c. Healing Stage III pressure ulcer
d. Stage III pressure ulcer

Answer 4

c. Healing Stage III pressure ulcer

Question 5

The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

Answer 5

b. Stage II

Question 6

Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?

a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Natural light

Answer 6

d. Natural light

Question 7

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?

a. Partial-thickness wound repair
b. Full-thickness wound repair
c. Primary intention
d. Tertiary intention

Answer 7

b. Full-thickness wound repair

Question 8

The nurse is caring for a group of patients. Which patient will the nurse see first?

a. A patient with a Stage IV pressure ulcer
b. A patient with a Braden Scale score of 18
c. A patient with appendicitis using a heating pad
d. A patient with an incision that is approximated

Answer 8

c. A patient with appendicitis using a heating pad

Question 9

The nurse is caring for a patient who is experiencing a full-thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing?

a. Eschar
b. Slough
c. Granulation
d. Purulent drainage

Answer 9

c. Granulation

Question 10

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention

Answer 10

d. Primary intention

Question 11

The nurse caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient?

a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention

Answer 11

b. Secondary intention

Question 12

Which nursing observation will indicate the patient’s wound healed by the process of secondary intention?

a. Minimal loss of tissue function
b. Permanent dark redness at site
c. Minimal scar tissue
d. Scarring that may be severe

Answer 12

d. Scarring that may be severe

Question 13

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the patient is experiencing a complication of wound healing?

a. Patient reporting, “My incision is hurting.”
b. Approximation of the incision edges has occurred.
c. Patient asks, “Why has my incision started to itch?”
d. The incision appears both swollen and bluish in color.

Answer 13

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

Question 14

Which finding will alert the nurse to a potential wound dehiscence?

a. Protrusion of visceral organs through a wound opening
b. Chronic drainage of fluid through the incision site
c. Report by patient that something has given way
d. Drainage that is odorous and purulent

Answer 14

c. Report by patient that something has given way

Question 15

Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer?

a. Vitamin E
b. Potassium
c. Prealbumin
d. Sodium

Answer 15

c. Prealbumin

Question 16

A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

a. Muscular strength assessment
b. Pulse oximetry assessment
c. Sensation assessment
d. Sleep assessment

Answer 16

b. Pulse oximetry assessment

Question 17

Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to?

a. Completing a head-to-toe assessment, including current treatment, vital signs, and aboratory results
b. Notifying the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR)
c. Consulting the wound care nurse about the change in status and the potential for infection
d. Conferring with the charge nurse about the change in status and the potential for infection

Answer 17

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

Question 18

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian?

a. Fat
b. Protein
c. Vitamin E
d. Carbohydrate

Answer 18

b. Protein

Question 19

The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain is currently in place. Which statement by the patient indicates issues with self-concept?

a. “I am so weak and tired. I just want to feel better.”
b. “I been thinking I will be ready to go home early next week.”
c. “I really need a bath and linen change right; I feel so awful.”
d. “I am hoping there will be something good to eat for my dinner tonight.”

Answer 19

c. “I really need a bath and linen change right; I feel so awful.”

Question 20

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?

a. Inspect the wound for bleeding.
b. Irrigate the wound to remove foreign bodies.
c. Measure and document the size of the wound.
d. Determine when the patient last had a tetanus antitoxin injection.

Answer 20

a. Inspect the wound for bleeding.

Question 21

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

a. Provide analgesic medications as ordered.
b. Avoid accidentally removing the drain.
c. Don sterile gloves.
d. Gather supplies.

Answer 21

a. Provide analgesic medications as ordered.

Question 22

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially?

a. Call the health care provider; a blockage is present in the tubing.
b. Chart the results on the intake and output flow sheet.
c. Do nothing, as long as the evacuator is compressed.
d. Remove the drain; a drain is no longer needed.

Answer 22

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

Question 23

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?

a. Low-air-loss
b. Air-fluidized
c. Lateral rotation
d. Standard mattress

Answer 23

b. Air-fluidized

Question 24

The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?

a. Increased monitoring of the wound condition
b. Documenting the wound’s status daily
c. Surgical debridement of the wound
d. Increased drainage from wound

Answer 24

c. Surgical debridement of the wound

Question 25

The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider’s order will the nurse question?

a. Use a low-air-loss therapy unit.
b. Irrigate with Dakin’s solution.
c. Apply a hydrogel dressing.
d. Consult a dietitian.

Answer 25

b. Irrigate with Dakin’s solution.

Question 26

The nurse is completing an assessment of the patient’s skin’s integrity. Which assessment is the priority?

a. Pressure points
b. Breath sounds
c. Bowel sounds
d. Pulse points

Answer 26

a. Pressure points

Question 27

The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?

a. 15
b. 17
c. 20
d. 23

Answer 27

c. 20

Question 28

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient’s willingness and ability to increase mobility?

a. Explain the risks of immobility to the patient.
b. Turn the patient every 3 hours while in bed.
c. Encourage the patient to sit up in the chair.
d. Provide analgesic medication as ordered.

Answer 28

d. Provide analgesic medication as ordered.

Question 29

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan?

a. Readiness for enhanced nutrition
b. Impaired physical mobility
c. Impaired skin integrity
d. Chronic pain

Answer 29

c. Impaired skin integrity

Question 30

The nurse documents the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?

a. Imbalanced nutrition: less than body requirements
b. Ineffective peripheral tissue perfusion
c. Risk for infection
d. Acute pain

Answer 30

b. Ineffective peripheral tissue perfusion

Question 31

The nurse caring for an immobile patient wants to decrease the risk of the formation of pressure ulcers. Which action will the nurse take first?

a. Offer favorite fluids.
b. Turn the patient every 2 hours.
c. Determine the patient’s risk factors.
d. Encourage increased quantities of carbohydrates and fats.

Answer 31

c. Determine the patient’s risk factors.

Question 32

Which health care team member will the nurse consult when a patient has received a nursing diagnosis of Impaired skin integrity?

a. Respiratory therapist
b. Registered dietitian
c. Case manager
d. Chaplain

Answer 32

b. Registered dietitian

Question 33

When a comatose patient develops a Stage II pressure ulcer, the nurse includes the nursing diagnosis of Risk for infection to the care plan. Which is the best goal for this patient?

a. The patient will state what to look for with regard to an infection.
b. The patient’s family will demonstrate specific care of the wound site.
c. The patient’s family members will wash their hands when visiting the patient.
d. The patient will remain free of odorous or purulent drainage from the wound.

Answer 33

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

Question 34

When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)?

a. Assessing a surgical patient for risk of pressure ulcers
b. Applying a gauze bandage to secure a nonsterile dressing
c. Treating a pressure ulcer on the buttocks of a medical patient
d. Implementing negative-pressure wound therapy on a stable patient

Answer 34

b. Applying a gauze bandage to secure a nonsterile dressing

Question 35

The nurse performing a moist-to-dry dressing has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the following steps, starting with the first one?

1. Apply sterile gloves.
2. Cover and secure topper dressing.
3. Assess wound and surrounding skin.
4. Moisten gauze with prescribed solution.
5. Gently wring out excess solution and unfold.
6. Loosely pack until all wound surfaces are in contact with gauze.

a. 4, 3, 1, 5, 6, 2
b. 1, 3, 4, 5, 6, 2
c. 4, 1, 3, 5, 6, 2
d. 1, 4, 3, 5, 6, 2

Answer 35

b. 1, 3, 4, 5, 6, 2

Question 36

The nurse is caring for a patient at risk for skin impairment. Which initial action should the nurse take to decrease this risk?

a. After cleansing thoroughly dry the skin.
b. Request a therapeutic bed and mattress.
c. Pad the bed with absorbent pads.
d. Use products that retain moisture.

Answer 36

a. After cleansing thoroughly dry the skin.

Question 37

A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair?

a. Less than 2 hours at any one time
b. For a total of least than 3 hours daily
c. No longer than 30 minutes out of every hour
d. Until the patient expresses being uncomfortable

Answer 37

a. Less than 2 hours at any one time

Question 38

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?

a. Place the patient in a 30-degree supine position.
b. Utilize a transfer device to lift the patient.
c. Elevate the head of the bed 45 degrees.
d. Slide the patient into the new position.

Answer 38

b. Utilize a transfer device to lift the patient.

Question 39

As prescribed, the nurse leaves the pressure ulcer open to air and does not apply a dressing. Which stage of ulcer did the nurse appropriately treat?

a. A Stage I
b. A Stage II
c. A Stage III
d. A Stage IV

Answer 39

a. A Stage I

Question 40

The patient appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take?

a. Distract the patient with the television.
b. Offer to explain what they should expect.
c. Suggest that the patient “Close your eyes.”
d. Wait until family is visiting to support the patient.

Answer 40

b. Offer to explain what they should expect.

Question 41

Which intervention should be included as the nurse cleanses a wound?

a. Allow the solution to flow from the most contaminated to the least contaminated.
b. Scrub vigorously when applying noncytotoxic solution to the skin.
c. Cleanse in a direction from the least contaminated area.
d. Utilize clean gauze and clean gloves to cleanse a site.

Answer 41

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

Question 42

Which is the best explanation for the nurse to provide when teaching the patient the reason for the binder after an open abdominal aortic aneurysm repair?

a. It reduces edema at the surgical site.
b. It secures the dressing in place.
c. It immobilizes the abdomen.
d. It supports the abdomen.

Answer 42

d. It supports the abdomen.

Question 43

The nurse is caring for a postoperative patient recovering from a medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?

a. Monitor vital signs every 15 minutes.
b. Check pulses in the right foot.
c. Keep the leg dependent.
d. Apply ice.

Answer 43

d. Apply ice.

Question 44

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

a. 12
b. 13
c. 20
d. 23

Answer 44

d. 23

Question 45

The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.)

a. Place moist sterile gauze over the site.
b. Gently place the organs back.
c. Contact the surgical team.
d. Offer a glass of water.
e. Monitor for shock.

Answer 45

a. Place moist sterile gauze over the site.
c. Contact the surgical team.
e. Monitor for shock.

Question 46

The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.)

a. Hemostasis
b. Maturation
c. Inflammatory
d. Proliferative
e. Reproduction
f. Reestablishment of epidermal layers

Answer 46

a. Hemostasis
b. Maturation
c. Inflammatory
d. Proliferative

Question 47

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)

a. “Can you easily change your position?”
b. “Do you have sensitivity to heat or cold?”
c. “How often do you need to use the toilet?”
d. “What medications do you take?”
e. “Is movement painful?”
f. “Have you ever fallen?”

Answer 47

a. “Can you easily change your position?”
b. “Do you have sensitivity to heat or cold?”
c. “How often do you need to use the toilet?”
e. “Is movement painful?”

Question 48

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)

a. Vision
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin

Answer 48

b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin

Question 49

The nurse is caring for a patient who will have a large abdominal bandage secured with an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.)

a. Cover exposed wounds.
b. Mark the sites of all abrasions.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
e. Cleanse the area with hydrogen peroxide.
f. Assess the skin at underlying areas for circulatory impairment.

Answer 49

a. Cover exposed wounds.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
f. Assess the skin at underlying areas for circulatory impairment.

Question 50

The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.)

a. The patient’s expectations are not being met.
b. Skin is intact with no redness or swelling.
c. Nonblanchable erythema is absent.
d. No injuries to the skin and tissues are evident.
e. Granulation tissue is present.

Answer 50

b. Skin is intact with no redness or swelling.
c. Nonblanchable erythema is absent.
d. No injuries to the skin and tissues are evident.
e. Granulation tissue is present.

Question 51

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description.

a. Absorbs drainage through the use of exudate absorbers in the dressing
b. Very soothing to the patient and do not adhere to the wound bed
c. Barrier to external fluids/bacteria but allows wound to “breathe”
d. Manufactured from seaweed and comes in sheet and rope form
e. Oldest and most common absorbent dressing

1. Gauze
2. Transparent
3. Hydrocolloid
4. Hydrogel
5. Calcium alginate

Answer 51

1. E
2. C
3. A
4. B
5. D