Chapter 48: Skin Integrity and Wound Care [Practice Test] Flashcards
A patient can lose ___ g of protein per day from an open weeping pressure ulcer. It would increase the protein intake up to ____ g/kg/day as necessary for healing
50
1.8
This type of dressing is used for partial thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation damage skin.
Hydrogel
What kind of dressing would you put on a clean stage III pressure ulcer. How does the wound heal and what are the effects?
Hydrocolloid.
Must change when Seal of dressing breaks.
Maximum wear time seven days. Hydrogel
covered with foam dressing.
Applied over wanted to protect and absorb moisture.
Calcium alginate.
Used with significant exit date must cover with secondary dressing.
Gauze
used with normal saline or other prescribe solution. must unfold to make contact with wound.
Growth factors.
Use with gauze per manufacturer instructions.
Heals through granulation and reepithelialization.
The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.
ANS: B
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.
4 commonly used cytotoxic solutions are? These ____ used to clean granulating wounds.
Dakin’s Solution (Sodium Hypochlorite) Acetic Acid
Povidone-Iodine
Hydrogen Peroxide
Are not
This form of wound debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instruments.
Surgical
____ is contraindicated if the wound site is edematous, or the patient has neuropathy
Cold
Slows circulation
_________ is the oldest and most common dressing they are absorbent and are useful in wicking away wound exudate. _____ is the most common size.
Gauze
4x4
The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.
ANS: A
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.
Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient’s capillary refill is less than 2 seconds.
ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.
The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words “healing stage.” Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.
________ breaks down and loosens dead tissue in a wound. Apply the solution to gauze and apply to wound. ________ are used in a wound because it is thought that they digest the dead tissue.
Dakin’s Solution
Sterile maggots
The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV.
ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.
Topical enzymes induced changes in the substrate resulting in the breakdown of necrotic tissue. Depending on the enzyme it either _____ or _____ the tissue. These require a ______.
digests or dissolves
Doctors Order
Use nonadherent dressing such as ______ on clean wounds with little or no drainage. This gauze has a shiny non-adherents service that does not stick to incisions or one openings but allows drainage to pass through to the gauze topper.
TEFLA
An order to reinforce dressings PRN as in add dressings without removing the original one is _____ right after surgery.
common
Rationale: when the doctor does not want accidental disruption of the suture line or bleeding.
The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment inspection and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first item used.
The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.
ANS: C
Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and remodeling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges approximated. Wound closure is delayed until risk of infection is resolved.
If the wound base is dry use a dressing that adds moisture, if there is excessive exudate use a dressing that absorbs the excess moisture while maintaining moisture at the wound bed during this form of wound debridement?
Autolytic Debridement
\_\_\_\_\_\_ and \_\_\_\_\_\_\_ are used for creating pressure over a body part. Immobilizing a body part. Supporting the wound. Reducing and preventing edema. Securing the splint. Securing dressings.
Bandages and binders
The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s).
a. 4
b. 2
c. 1
d. 7
ANS: A
A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry.
The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair?
a. Eschar
b. Slough
c. Granulation
d. Purulent drainage
ANS: C
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal.
Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.
When irrigating allow the solution to flow from the _____ contaminated area.
least to most
The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.
ANS: D
A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.
This is a nonselective method of debridement because devitalized and viable tissues are both removed. This is not used routinely. Never use this method and a clean granulating wound. What is this defined as?
Mechanical Debridement
_______ are via available in a variety of materials including silk steel cotton linen wire nylon and Dacron.
Sutures
The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.
ANS: B
A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial- thickness repair are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved.
This form of wound debridement uses topical enzyme preparation, Dakin’s solution, or sterile maggots.
Chemical
Pressure dressing to use during the first ______ hours after trauma helps maintain hemostasis.
24 to 48
Which nursing observation would indicate that a wound healed by secondary intention?
a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at site
d. Scarring can be severe.
ANS: D
A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.
When a laceration is bleeding profusely what is your number one concern?
Maintaining hemostasis
This type of dressing is most useful on shallow to moderately deep dermal ulcers. This dressing leaves a residue in the wound bed that is easy to confuse with purulent drainage.
Hydrocolloid
________ can be saturated with solution and used to clean and pack a wound. It is saturated with solution usually saline, wrung out, unfolded, and lightly packed into the wound. The purpose of this is to provide moisture to the wound yet allow wound drainage to be wicked into the pad. ______ the dressing allows easier wicking action.
Gauze
Unfolding
High pressure wound irrigation.
Pulsitile high-pressure Lavage. Whirlpool treatments.
These are all what method of wound debridement.
Mechanical
The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing?
a. The incision site has started to itch.
b. The incision site is approximated.
c. The patient has pain at the incision site.
d. The incision has a mass, bluish in color.
ANS: D
A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.
What kind of dressing would you put on a clean stage IV pressure ulcer? What are the effects? how does the wound heal?
Hydrogel
covered with foam dressing.
Applied over wound to protect and absorb moisture.
Calcium alginate. Used with significant exudate.
Must cover with secondary dressing.
Gauze
Use with normal saline or other prescribe solution.
Must unfold to make contact with wild. Fills all dead space with gauze.
Growth factors.
Used with gauze.
Heals through granulation and re-epithelialization.
Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?
a. Complaint by patient that something has given way
b. Protrusion of visceral organs through a wound opening
c. Chronic drainage of fluid through the incision site
d. Drainage that is odorous and purulent
ANS: A
occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.
What kind of dressing would you put on an unstageable pressure ulcer and what are the effects? How does the wound heal?
Adherent film. Facilitates softening of Eschar. Gauze plus ordered solution. Deliver solution in wicks wound drainage and softens eschar. Enzymes. Facilitates the debridement. None. If eshar is dry and intact no dressing used allowing eschar to act as physiological cover maybe indicated for treatment of heal eschar.
Adherent film Eschar lifts at edges of debridement progresses. Gauze plus solution Eschar softens Enzymes Eschar softens.
A patient has developed a decubitus ulcer. What laboratory data would be important to gather?
a. Serum albumin
b. Creatine kinase
c. Vitamin E
d. Potassium
ANS: A
Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested, but also what the body has absorbed, digested, and metabolized. Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing.
Hemoglobin needs to be maintained at _______. If not maintained decreases delivery of oxygen to the tissues and leads to further ischemia.
12g/100mL
Which of the following would be the most important piece of assessment data to gather with regard to wound healing?
a. Muscular strength assessment
b. Sleep assessment
c. Pulse oximetry assessment
d. Sensation assessment
ANS: C
Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment. Oxygen diffuses from the alveoli into the pulmonary blood; most of the oxygen attaches to hemoglobin molecules within the red blood cells. Red blood cells carry oxygenated hemoglobin molecules through the left side of the heart and out to the peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.
The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
A. Complete her assessment
B. Document findings as normal
C. Notify the Physician
D. Notify the Charge Nurse
ANS: A
The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient’s status and on any new orders.
