Tissue integrity

Question 1

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5° F temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make?

a. The abdominal incision shows signs of an infection.
b. The patient is having a normal inflammatory response.
c. The abdominal incision shows signs of impending dehiscence.
d. The patient’s physician must be notified about her condition.

Answer 1

b

Question 2

The nurse assessing a patient with a chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. What would the nurse anticipate being ordered to assess the patient’s systemic response?

a. Serum protein analysis
b. WBC count and differential
c. Punch biopsy of center of wound
d. Culture and sensitivity of the wound

Answer 2

b

Question 3

A patient in the unit has a 103.7° F temperature. Which intervention would be most effective in restoring normal body temperature?

a. Use a cooling blanket while the patient is febrile.
b. Administer antipyretics on an around-the-clock schedule.
c. Provide increased fluids and have the UAP give sponge baths.
d. Give prescribed antibiotics and provide warm blankets for comfort.

Answer 3

b

Question 4

A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur?

a. Tertiary intention
b. Secondary intention
c. Regeneration of cells
d. Remodeling of tissues

Answer 4

b

Question 5

A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient’s WBC count is 15.0 × 106/µL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient’s ability to heal?

a. Imbalanced nutrition: obesity related to high-fat foods
b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking
c. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking
d. Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking

Answer 5

b

Question 6

Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer?

a. Pack the ulcer with foam dressing.
b. Turn and position the patient every hour.
c. Clean the ulcer every shift with Dakin’s solution.
d. Assess for pain and medicate before dressing change.

Answer 6

c

Question 7

An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, how should the nurse plan for this patient’s care?

a. Implement a 1-hr turning schedule with skin assessment.
b. Place DuoDerm on the patient’s sacrum to prevent breakdown.
c. Elevate the head of bed to 90 degrees when the patient is supine.
d. Continue with weekly skin assessments with no special precautions.

Answer 7

a

Question 8

A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are most appropriate (select all that apply)?

a. Acute pain related to tissue damage and inflammation
b. Impaired skin integrity related to immobility and decreased sensation
c. Impaired tissue integrity related to inadequate circulation secondary to pressure
d. Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke
e. Ineffective peripheral tissue perfusion related to arteriosclerosis and loss of blood supply to affected area

Answer 8

b,c

Question 9

An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?

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

Answer 9

c

Question 10

Skin

Answer 10

Largest organ in the body

Supports critical life functions

Question 11

Alterations=damage to

Answer 11

Epidermal or dermal layers of skin

Deep tissues

Question 12

Epidermis

Answer 12

Outer layer
5 interrelated layers
Major cells
Keratinocytes
Melanocytes

Question 13

Dermis

Answer 13

Three types of connective tissue
Collagen
Elastic fibers
Reticular fibers
Major cell
Fibroblast

Question 14

Subcutaneous tissue

Answer 14

Loose connective tissue and fat cells
Attaches skin to muscles and bones
Distribution varies

Question 15

Skin appendages

Answer 15

Hair
Nails
Glands
Sebaceous
Sweat
Apocrine
Eccrine

Question 16

Infant considerations

Answer 16

Skin
40-50% thinner than adults
Erythematous (red) at birth—then fades
Skin color is early detector of potential problems
Blotchy or mottled—extremities (acrocyanosis)

Glands
Sebaceous glands on face (milia)
Sweat gland present at birth
No sweating for first 24 hours

Common alterations
Mongolian spots
Nevi
Erythema toxicum

Question 17

Pregnancy considerations

Answer 17

Skin
↑Melanotropin=Hyperpigmentation
Melasma
Linea nigra
↑Estrogen=↑blood flow to skin
Angiomatas (vascular spiders)
Palmar erythema
Mechanical stretching
Striae gravidarum (stretch marks)
Hair and nails
Accelerated growth
Hirsutism

Question 18

Older Adults considerations

Answer 18

Skin
Less elastic + thinner = ↑in skin fragility
↑Risk of irritation or breakdown
Loss of subcutaneous fat=↑lines, wrinkles and sagging
↓%melanocytes→ cluster together=age spots
↓skin immune response=↑risk of skin infections
Hair
Thins and grays (scalp, pubic, axillary)
Thickens (nose and ears)
Men may grow more eyebrow, ear, and nostril hair
Women may grow facial hair

Nails
Slowed growth
Fragile and brittle
Sweat glands
Fewer in number
Function is lessened

Question 19

Nursing assessment health history

Answer 19

Past Medical History
Liver disease, cyanosis, 
Medications
Acne or OTC for symptoms
Surgery
Skin biopsies
Cosmetic or reconstructive
Self-care habits
Hygiene & personal care products
Sunscreen use
Nutrition
Condition of skin, hair, nails & mucus membranes
Food allergies that cause skin reaction

Elimination
Fluid balance
Dehydration or edema
Urinary or fecal incontinence
Activity-Exercise
Skin changes during exercise
Adequate mobility
Sleep-Rest
Symptoms interrupting sleep
Cognitive-Sensory
Orientation 
Sense heat, cold, pain, and touch
Numbness, tingling, or crawling sensations

Question 20

Diagnostics

Answer 20

Biopsy
Identify cause of skin lesions
Culture
Identify fungal, bacterial or viral organisms
Patch test
Assess for allergic reactions
Woods lamp
Assess for infectious organisms

Question 21

The primary function of the skin is

a. insulation.
b. protection.
c. sensation.
d. absorption.

Answer 21

b

Question 22

Age-related changes in the hair and nails include (select all that apply)

a. oily scalp.
b. scaly scalp.
c. thinner nails.
d. thicker, brittle nails.
e. longitudinal nail ridging.

Answer 22

b,d,e

Question 23

When assessing the nutritional-metabolic pattern in relation to the skin, the nurse questions the patient regarding

a. joint pain.
b. the use of moisturizing shampoo.
c. recent changes in wound healing.
d. self-care habits related to daily hygiene.

Answer 23

c

Question 24

During the physical examination of a patient’s skin, the nurse would

a. use a flashlight in a poorly lit room.
b. note cool, moist skin as a normal finding.
c. pinch up a fold of skin to assess for turgor.
d. perform a lesion-specific examination first and then a general inspection.

Answer 24

c

Question 25

The nurse assessed the patient’s skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called

a. wheals.
b. papules.
c. pustules.
d. plaques.

Answer 25

a

Question 26

To assess the skin for temperature and moisture, the most appropriate technique for the nurse to use is

a. palpation.
b. inspection.
c. percussion.
d. auscultation.

Answer 26

a

Question 27

Persons with dark skin are more likely to develop

a. keloids.
b. wrinkles.
c. skin rashes.
d. skin cancer.

Answer 27

a

Question 28

On inspection of a patient’s dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called

a. vitiligo.
b. intertrigo.
c. Nevus of Ota.
d. telangiectasia.

Answer 28

c

Question 29

Diagnostic testing is recommended for skin lesions when

a. a health history cannot be obtained.
b. a more definitive diagnosis is needed.
c. percussion reveals an abnormal finding.
d. treatment with prescribed medication has failed.

Answer 29

b

Question 30

When documenting normal findings of an assessment of the patient’s skin, which entry by the nurse is most appropriate?

a. “Skin warm and dry; turgor good; nails flat and pink; old surgical scars noted on abdomen.”
b. “History of allergic rashes, skin very fair with numerous freckles, warm and intact; no lesions noted.”

c. “Skin brown, slightly moist and warm; turgor immediate return; no lesions noted; states no problems
with skin.”

d. “No history of skin problems; skin intact, pink, temperature cooler in extremities; no lesions except numerous brown moles.”

Answer 30

c. “Skin brown, slightly moist and warm; turgor immediate return; no lesions noted; states no problems
with skin.”

Rationale: Scars, freckles (macules), and moles (nevus) would be skin lesions (abnormalities). Skin turgor that is normal should be described as “no tenting.”

Question 31

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?

a. Patch test instruments
b. Sterile gloves
c. Cotton-tipped applicators
d. Syringe and intra-dermal needle

Answer 31

Rationale: Culture uses cotton-tipped applicator to obtain drainage specimen.

Question 32

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy?

a. Low serum albumin level
b. Serosanguinous drainage
c. Deep red and moist wound bed
d. Cobblestone appearance of wound

Answer 32

a.

Rationale: Low serum albumin levels cause delayed wound healing.

Question 33

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer?

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

Answer 33

c

Rationale: Stage III involves subcutaneous tissue.

Question 34

After the home health nurse teaches a patient’s family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?

a. The family member uses a lift sheet to reposition the patient.
b. The family member uses clean tap water to clean the wound.
c. The family member dries the wound using a hair dryer on a low setting.
d. The family member places contaminated dressings in a plastic grocery bag.

Answer 34

c. The family member dries the wound using a hair dryer on a low setting.

Rationale: Wound bed needs to be moist.

Question 35

What tool is used to assess for pressure ulcer risk? (Tissue Integrity)

Answer 35

a. Braden score

Question 36

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide?
Select all that apply.

 Wear sunglasses.
Drink plenty of water.
Eat plenty of foods high in vitamin K.
Apply sunscreen 30 minutes prior to exposure.
Consume fish oil and vitamin E.

Answer 36

Wear sunglasses.
Apply sunscreen 30 minutes prior to exposure.
Consume fish oil and vitamin E.

Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and has not been indicated.

Question 37

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient’s daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan?
Select all that apply.

Cleansing the wound
Managing pain
Applying a dry sterile dressing
Using cold water in the bath

Answer 37

Cleansing the wound and managing pain

Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

Question 38

The nurse would explain to a patient that effective treatments for atopic pruritus include which treatments?
Select all that apply.

 Oral steroids
Topical steroids
Oral antihistamines
Topical antihistamines
Topical petroleum ointment

Answer 38

Oral steroids and Topical steroids

Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical antihistamines are not usually given, because they are ineffective and may cause further irritation. Petroleum is also ineffective.

Question 39

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to perform which actions?
Select all that apply.

Bathe and dry the skin vigorously to stimulate circulation.
Keep the head of the bed elevated 30 degrees.
Offer nutritional supplements and frequent snacks.
Turn the patient at least every 2 hours.
Maintain a cooler environment when bathing.

Answer 39

Offer nutritional supplements and frequent snacks.
and
Turn the patient at least every 2 hours

The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein–calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline. Older adults are more prone to hypothermia if bathed in a cooler environment.

Question 40

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant?
Select all that apply.

Applying over-the-counter lotions to skin that is not broken
Assisting the client with frequent turning to prevent pressure ulcers
Covering the client who complains of being cold with more blankets
Placing a sterile gauze pad over broken skin to contain drainage
Assessing a patient complaining of an itching rash

Answer 40

Applying over-the-counter lotions to skin that is not broken
Assisting the client with frequent turning to prevent pressure ulcers
Covering the client who complains of being cold with more blankets
Placing a sterile gauze pad over broken skin to contain drainage

All the above options can be delegated to an unlicensed assistive personnel employee except assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

Question 41

What is the removal of devitalized tissue from a wound called?

Debridement

Pressure reduction

Negative pressure wound therapy

Sanitization

Answer 41

Debridement

Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

Question 42

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

Binder

Ice bag

Elastic bandage

Absorptive dressing

Answer 42

Ice bag

An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

Question 43

On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient’s pressure ulcer?

Category/Stage II

Category/Stage IV

Unstageable

Suspected deep tissue damage

Answer 43

Unstageable

To determine the category/stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

Question 44

What is the correct sequence of steps when performing a wound irrigation? 1. Use slow continuous pressure to irrigate wound. 2. Attach angio catheter to syringe 3. Fill syringe with irrigation fluid 4. Place water proof bag near bed 5. Position angio catheter over wound

4, 3, 2, 5, 1

3, 4, 2, 1, 5

4, 2, 3, 5, 1

2, 3, 4, 5, 1

Answer 44

4, 3, 2, 5, 1

Organized steps ensure a safe effective irrigation of the wound.

Question 45

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?

A local skin infection requiring antibiotics

Sensitive skin that requires special bed linen

A stage III pressure ulcer needing the appropriate dressing

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

Answer 45

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

Question 46

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

Necrotic tissue

Wound drainage

Wound circumference

Cleansed wound

Answer 46

Cleansed wound

Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

Question 47

What does the Braden Scale evaluate?

Skin integrity at bony prominences, including any wounds

Risk factors that place the patient at risk for skin breakdown

The amount of repositioning that the patient can tolerate

The factors that place the patient at risk for poor healing

Answer 47

Risk factors that place the patient at risk for skin breakdown

The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

Question 48

Which of the following are measures to reduce tissue damage from shear?
Select all that apply.

Use a transfer device, e.g. transfer board
Have head of bed elevated when transferring patient
Have head of bed flat when re positioning patients
Raise head of bed 60 degrees when patient positioned supine
Raise head of bed 30 degrees when patient positioned supine

Answer 48

Use a transfer device, e.g. transfer board

Have head of bed flat when re positioning patients

Raise head of bed 30 degrees when patient positioned supine

A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed to be elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position will cause patient to slide down, causing shear.

Question 49

After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions?
Select all that apply.

Notify the surgeon
Allow the area to be exposed to air until all drainage has stopped
Place several cold packs over the area, protecting the skin around the wound
Cover the area with sterile, saline-soaked towels and immediately.
Cover the area with sterile gauze and apply an abdominal binder

Answer 49

Notify the surgeon

If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

Question 50

Which of the following describes a hydrocolloid dressing?

A seaweed derivative that is highly absorptive

Premoistened gauze placed over a granulating wound

A debriding enzyme that is used to remove necrotic tissue

A dressing that forms a gel that interacts with the wound surface

Answer 50

A dressing that forms a gel that interacts with the wound surface

A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

Question 51

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?
Select all that apply.

Collection of wound drainage
Provides support to abdominal tissues when coughing or walking
Reduction of abdominal swelling
Reduction of stress on the abdominal incision
Stimulation of peristalsis (return of bowel function) from direct pressure

Answer 51

Provides support to abdominal tissues when coughing or walking

Reduction of stress on the abdominal incision

A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.