skin Flashcards
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
Alteration in level of consciousness.
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
Pressure.
Which nursing observation would indicate that the patient was at risk for pressure ulcer
formation?
The patient has fecal incontinence.
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?
Healing stage III pressure ulcer
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
II
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?
Halogen light
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
Full-thickness wound repair.
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).
4
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?
Granulation
The nurse is caring for a patient who has experienced a laparoscopic appendectomy.
The nurse recalls that this type of wound heals by
Primary intention
The nurse is caring for a patient in the burn unit. The nurse recalls that this type of
wound heals by
secondary intention
Which nursing observation would indicate that a wound healed by secondary
intention?
Scarring can be severe.
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?
The incision has a mass, bluish in color.
Which of these findings if seen in a postoperative patient should the nurse associate
with dehiscence?
Complaint by patient that something has given way
A patient has developed a decubitus ulcer. What laboratory data would be important to
gather?
Serum albumin
Which of the following would be the most important piece of assessment data to gather
with regard to wound healing?
Pulse oximetry assessment
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?
Complete the head-to-toe assessment, and include current treatment, vital signs, and
laboratory results.
The nurse is collaborating with the dietitian about a patient with a stage III pressure
ulcer. After the collaboration, the nurse orders a meal plan that includes increased
protein
The nurse is completing an assessment on an individual who has a stage IV pressure
ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient
is experiencing issues with self-concept when the patient states which of the following?
“I am ready for my bath and linen change as soon as possible.”
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, the next best step is to
Inspect the wound for bleeding.
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 of these actions should the nurse take first?
Provide analgesic medications as ordered.
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. What would be the
nurse’s next best step?
Call the physician; a blockage is present in the tubing.
The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic
surgery consultation. Which of the following specialty beds would be most appropriate?
Nonpowered redistribution air mattress
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black.
The nurse recognizes that the next step in caring for this patient includes
Débridement of the wound.
The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is
clean and granulating. Which of the following orders would the nurse question?
Irrigate with hydrogen peroxide.
The nurse is completing an assessment of the skin’s integrity, which includes
Pressure points.
The nurse is completing a skin risk assessment utilizing the Braden scale. The patient
has some sensory impairment and 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. What would be the patient’s Braden scale total score?
20
The nurse is caring for a medical-surgical patient. To decrease the risk of pressure
ulcers and encourage the patient’s willingness and ability to increase mobility, which intervention
is most important for the nurse to complete?
Provide analgesic medication as ordered.
The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns
which of the following nursing diagnoses?
Impaired skin integrity
The nurse has collected the following assessment data: right heel with reddened area
that does not blanch. What nursing diagnosis would the nurse assign?
Ineffective tissue perfusion
The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned
a nursing diagnosis of Risk for infection. Which intervention would be most important for this
patient?
Encourage thorough handwashing of all individuals caring for the patient.
The medical-surgical acute care patient has received a nursing diagnosis of Impaired
skin integrity. The nurse consults a
Registered dietitian.
The nurse is caring for a patient with a stage II pressure ulcer and has assigned a
nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is
completing the plan of care and is writing goals for the patient. What is the best goal for this
patient?
The patient will remain free of an increase in temperature and of odorous or
purulent drainage from the wound.
The nurse is caring for a postpartum patient. The patient has an episiotomy after
experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing
this treatment. This patient is at risk for
trauma
The home health nurse is caring for a patient with impaired skin integrity in the home.
The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing
the expenses associated with long-term wound care?
Clean dressings and no touch technique
The nurse is caring for a patient who has suffered a stroke and has residual mobility
problems. The patient is at risk for skin impairment. Which initial interventions should the nurse
select to decrease this risk?
Gentle cleaners and thorough drying of the skin
The nurse is caring for a patient who is at risk for skin impairment. The patient is able
to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the
nurse schedule the patient to sit in the chair?
Less than 2 hours
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. What is the best method for repositioning the patient?
Utilize a transfer sliding board and assistance to slide the patient into the new
position.
The nurse is staffing a medical-surgical unit that is assigned most of the patients with
pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes
that a staged pressure ulcer that does not require a dressing is stage
I
The nurse is caring for a patient with a wound. The patient appears anxious as the
nurse is preparing to change the dressing. What should the nurse do to decrease the patient’s
anxiety?
Explain the procedure.
The nurse is cleansing a wound site. As the nurse administers the procedure, what
intervention should be included?
Cleansing in a direction from the least contaminated area
The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The
nurse requests an abdominal binder and carefully applies the binder. What is the best explanation
for the nurse to use when teaching the patient the reason for the binder?
The binder supports the abdomen.
The nurse is caring for a postoperative medial meniscus repair of the right knee. To
assist with pain management following the procedure, which intervention should the nurse
implement?
Elevate right knee and apply ice.
The patient has been provided a nursing diagnosis of Risk for skin impairment and has
a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing
diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin
breakdown is decreasing?
23
The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of
care understands the need for a multidisciplinary approach. The nurse evaluates the need for
several consults. Which of the following should always be included in the consults? (Select all that
apply.)
a. Registered dietitian
b. Enterostomal and wound care nurse
c. Physical therapist
d. Case management personnel
The nurse is caring for a patient with wound healing by tertiary intention. Which factors
does the nurse recognize as influencing wound healing? (Select all that apply.)
a. Nutrition
c. Tissue perfusion
d. Infection
f. Age
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. “Is movement painful?”
The nurse is caring for a patient with potential skin breakdown. Which components
would the nurse include in the skin assessment? (Select all that apply.)
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
The nurse is caring for a patient who will have both a large abdominal bandage and an
abdominal binder. The nurse’s responsibilities and activities before applying the bandage and
binder include which of the following? (Select all that apply.)
a. Inspecting the skin for abrasions and edema
b. Covering exposed wounds
c. Assessing condition of current dressings
d. Assessing the skin at underlying areas for circulatory impairment
The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a
nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate
progression toward goals? (Select all that apply.)
b. Prevent injury to the skin and tissues.
d. Reduce injury to the skin.
e. Reduce injury to the underlying tissues.
f. Restore skin integrity.
