tissue integrity Flashcards
- Which of the following is a primary goal for a patient with impaired tissue integrity?
A. Maintain oxygen saturation levels above 95%
B. Prevent infection and promote wound healing
C. Increase fluid intake to 3000 mL daily
Answer: B
Rationale: The primary goal for patients with impaired tissue integrity is to prevent infection and promote healing
Which intervention is most appropriate for a patient with a stage 3 pressure injury?
A. Application of a hydrocolloid dressing
B. Debridement of necrotic tissue
C. No dressing is needed for stage 3 injuries
Answer: B
Rationale: Stage 3 pressure injuries often require debridement of necrotic tissue to promote healing
- A patient with a venous ulcer requires frequent dressing changes. Which type of dressing is most appropriate?
A. Transparent film
B. Wet-to-moist dressing
C. Hydrogel
Answer: B
Rationale: Wet-to-moist dressings are effective in keeping the wound bed moist, which aids in debridement and healing
- A patient reports itching and redness after the application of a topical medication. What is the priority action?
A. Apply more medication to see if the reaction subsides
B. Clean the area and notify the provider
C. Stop the medication and observe the site
Answer: B
Rationale: An allergic reaction to topical medication should be reported and the site should be cleaned
- Which of the following is a key factor in wound healing?
A. Tissue perfusion
B. Dry environment
C. Excessive pressure on the wound site
Answer: A
Rationale: Adequate tissue perfusion is essential for delivering oxygen and nutrients to support healing
- Which factors contribute to impaired wound healing? (Select all that apply.)
A. Diabetes
B. Inadequate nutrition
C. Hypoxia
D. Limited movement
E. Hypertension
Answer: A, B, C
Rationale: Diabetes, poor nutrition, and hypoxia impair the body’s ability to heal wounds
The nurse is teaching a patient with a history of pressure ulcers about prevention. Which statements indicate understanding? (Select all that apply.)
A. “I should change positions frequently.”
B. “I will use a soft foam cushion while sitting.”
C. “I should avoid moisturizing my skin.”
D. “I need to check my skin daily for redness.”
Answer: A, B, D
Rationale: Repositioning, using pressure-relieving devices, and inspecting the skin are important in preventing pressure ulcers
- Which of the following are common signs of infection in a wound? (Select all that apply.)
A. Redness around the wound
B. Increased pain
C. Decreased warmth
D. Foul-smelling drainage
Answer: A, B, D
Rationale: Redness, increased pain, and foul-smelling drainage are signs of infection
- When assessing a pressure ulcer, which of the following should be documented? (Select all that apply.)
A. Location of the wound
B. Presence of necrotic tissue
C. Length, width, and depth of the wound
D. Patient’s weight
Answer: A, B, C
Rationale: Location, necrotic tissue, and wound dimensions are essential aspects of wound documentation
- The nurse is caring for a patient with a wet-to-moist dressing. Which actions are appropriate? (Select all that apply.)
A. Remove the dressing when it is completely dry
B. Moisten the dressing with normal saline before applying
C. Ensure the dressing is moist, not soaked
D. Change the dressing at least twice daily
Answer: B, C, D
Rationale: Wet-to-moist dressings should be moistened before application, kept moist but not soaked, and changed frequently to promote healing
- Negative pressure wound therapy helps accelerate wound healing by removing fluid and reducing edema.
Answer: True
Rationale: Negative pressure wound therapy assists wound healing by promoting the removal of excess fluid, reducing edema, and improving perfusion to the wound bed
- Application of a hydrocolloid dressing is recommended for heavily draining wounds.
Answer: False
Rationale: Hydrocolloid dressings are used for wounds with minimal to moderate exudate, not for heavily draining wounds
- Wet-to-dry dressings are used primarily for mechanical debridement of necrotic tissue.
Answer: True
Rationale: Wet-to-dry dressings are effective in mechanically debriding necrotic tissue from wounds
- A Braden score of 19 indicates that the patient is at high risk for developing pressure ulcers.
Answer: False
Rationale: A Braden score of 19 indicates low risk. Scores below 12 indicate high risk
- Keeping the wound environment dry is ideal for promoting tissue regeneration.
Answer: False
Rationale: A moist wound environment promotes better tissue regeneration and faster healing
