Unit 6 CHAPTER 29 Wounds&Skin Integrity Practice Questions Flashcards
The nurse has just reassessed the condition of a post- operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which pa- rameter most carefully during the next hour?
1. Urinary output of 20 mL/hr
2. Temperature of 37.6° C (99.6° F)
3. Blood pressure of 100/70 mm Hg
4. Serous drainage on the surgical dressing
- Urinary output of 20 mL/hr
- Answer: 1
Rationale: Urine output would be maintained at a mini- mum of 30 mL/hr for an adult. An output of less than 30 mL for 2 consecutive hours needs to be reported to the surgeon. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable imme- diately. The client’s preoperative or baseline blood pres- sure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
- On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that, when pressed lightly, does not blanch. What does this assessment cue indicate to the nurse?
a. The presence of an infection in the area
b. The presence of a stage 1 pressure injury
c. An allergic reaction to the sheets
d. The need to apply a cold compress to reduce inflammation
b. The presence of a stage 1 pressure injury
rationale- Answer: b
Nonblanchable erythema over an area of pressure defines a stage 1 pressure injury. An infection is likely to occur in an open sore and is associated with signs of redness, warmth, and green or yellow exudate. An allergic reaction manifests as a rash or itchy area. Cold compresses cause vasoconstriction and further damage because the blood flow has already been restricted.
Four days after abdominal surgery, the patient is getting out of bed and feels something “pop” in his abdominal wound. An increase in amount of drainage from the wound is seen, and further examination shows that the sutured incision is now partially open, with tissue protruding from the wound. Which are the priority nursing interventions? (Select all that apply.)
a. Apply Steri-Strips to close the wound edges.
b. Cover the wound with saline-moistened gauze.
c. Apply a binder to pull the wound edges together and provide support to the edges.
d. Notify the surgeon.
e. Allow the area to be exposed to air until all of the drainage has stopped.
Answer: b, d
b. Cover the wound with saline-moistened gauze.
d. Notify the surgeon.
This is likely to be an evisceration of the surgical wound and, as such, may require surgical intervention. The normal saline keeps the wound and tissue moist until they can be evaluated by the surgeon. Steri-Strips can be used to reinforce a closed wound when sutures or staples are removed but are not used to try to close a wound that has opened and has tissue protruding through. A binder is used to support a closed incision and should not be applied to a wound with tissue protruding. Allowing the area to be exposed puts the patient at risk for infection.
. Which features are characteristic of a closed drainage system, such as a Jackson-Pratt (JP) drain? (Select all that apply.)
a. Works by gravity
b. Provides for early discharge
c. Usually is inserted in surgery
d. Reduces the amount of antibiotics required
e. Allows for accurate measurement of wound drainage
Answers: c, e
JP drains usually are inserted at surgery. Unlike an open drainage device (such as the Penrose drain), a JP drain does not allow drainage to soak into the surrounding dressing and allows for an accurate measurement of the drainage. JP drains work by suction, not gravity. Discharge and antibiotic use are not dependent on the type of drain.
A patient has a stage 3 pressure injury on the coccyx. Which food will be most beneficial in improving the healing process?
a. Food high in vitamin D
b. Whole-grain carbohydrates
c. High-calorie, high-protein drink
d. Food high in fat and water content
c. High-calorie, high-protein drink
A stage 3 pressure injury takes months to heal, and nutrition is an important aspect of care. Important nutritional components related to healing are calories, protein, vitamins A and C, and minerals zinc and copper. Therefore, the supplements high in calories and protein would be most beneficial.
A patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. His physician has ordered him to be up in a chair for part of the day. What does the nurse recognize as the patient’s greatest risk factor for development of pressure injuries?
a. Moisture from incontinence
b. Nutritional deficiencies
c. Pressure and shear
d. Aging
c. Pressure and shear
Sitting in a chair increases pressure on the seating surface and the inability to maintain position, resulting in sliding down, adding the destructive element of shear. Nutritional deficits, moisture, and skin changes with age can be contributing factors for pressure injury development but do not relate to being up in the chair.
Which patient is at highest risk for impaired wound healing?
a. A 22-year-old with a pelvic fracture incurred in a motor vehicle accident
b. A 49-year-old with a history of smoking two packs a day who just had abdominal surgery
c. A 72-year-old with diabetes and cardiovascular disease who had surgical repair of a broken hip
d. A 90-year-old with no chronic health conditions with a small blistered burn on the hand
c. A 72-year-old with diabetes and cardiovascular disease who had surgical repair of a broken hip
Although all of these patients have risk factors for impaired healing, the 72-year-old patient has the most risk factors: increased age, comorbid conditions of diabetes and cardiovascular disease, and an injury that often affects the ability to move independently. The 22-year-old accident victim does not have any risk factors other than the pelvic fracture. The 49-year-old surgical patient who smokes is at risk for delayed healing due to vasoconstriction but would not have as great a risk as the 72-year-old. The burn with a blister is not a deep injury, and the patient has no risk factors other than age.
To reduce pressure points that may lead to pressure ulcers, the nurse should:
1. Position the client directly on the trochanter when side-lying
2. Use a donut device for the client when sitting up
4. Elevate the head of the bed as little as possible
5. Massage over the bony prominences
- Elevate the head of the bed as little as possible
The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is:
1. A reduced skin elasticity is common in the older adult
2. The attachment between the epidermis and dermis is weaker
3. The older client has less subcutaneous padding on the elbows
4. Older adults have a poor diet that increases risk for pressure ulcers
- The older client has less subcutaneous padding on the elbows
- What is the removal of devitalized tissue from a wound called?
- Debridement
- Pressure distribution
- Negative-pressure wound therapy
- Sanitization
- Debridement
What is Sharp debridement?
-Sharp debridement is the use of a sharp instrument (scalpel, cure e, or scissors) by health care personnel with appropriate training, to remove necrotic tissue. I
- It is the fastest way of removing nonviable tissue and is the method of choice if an underlying infection is suspected or if a large amount of necrotic tissue needs to be removed rapidly.
-Caution is used in patients with bleeding disorders.
What stage pressure ulcer is this?
a. Partial-thickness loss of skin with exposed dermis.The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. ‘This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive. related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Stage 1
Stage 2
Stage 3
Stage 4
Stage 2
What stage pressure ulcer is this?
b. Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration;these may indicate deep tissue pressure injury.
Stage 1
Stage 2
Stage 3
Stage 4
Stage 1
What stage pressure ulcer is this?
c. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer Slough and/ or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
Stage 1
Stage 2
Stage 3
Stage 4
Stage 4
What stage pressure ulcer is this?
d.Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/ or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
Stage 1
Stage 2
Stage 3
Stage 4
Stage 3
Which of the following describes a hydrocolloid dressing?
1. A seaweed derivative that is highly absorptive
2. Premoistened gauze placed over a granulating wound
3. A debriding enzyme that is used to remove necrotic tissue
4. A dressing that forms a gel that interacts with the wound surface
- A dressing that forms a gel that interacts with the wound surface
The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis of Impaired skin integrity?
a. Patient will ambulate twice a day.
b. Patient will eat 50% of meals.
c. Patient will have no further skin breakdown.
d. Patient will interact with others.
c. Patient will have no further skin breakdown.
The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.
The nurse knows which description would be classified as a closed wound?
a. A large bruise on the side of the face
b. A surgical incision that is sutured closed
c. A puncture wound that is healing
d. An abrasion on the leg
ANS: A
In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin’s surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.
The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?
a. “The wound will be red.”
b. “The wound will have pus.”
c. “The wound will be warm.”
d. “The wound will need to be treated.”
ANS: B
An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105/g of tissue sampled when cultured. The wound will need to be treated for the infection.
The nurse identifies which type of wounds heals by tertiary intention?
a. An acute wound in which the patient has sutures placed when it happened
b. A pressure injury that was treated with dressing changes and is healed
c. An acute wound in which surgical glue was used to close the wound
d. A wound that was left open initially and is delayed and closed later with sutures
ANS: D
When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure injury. takes 1 year to heal
The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a “popping sensation” and a wetness in the dressing, the nurse immediately suspects which complication?
a. A wound infection
b. The stitches came loose
c. Wound dehiscence
d. Fistula formation
ANS: C
Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage. A fistula is an abnormal connection between two internal organs or between an internal organ and, through the skin, the outside of the body.
The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure injuries, the nurse should place the head of the bed in which position?
a. Flat
b. 90 degrees
c. 30 degrees
d. 45 degrees
ANS: C
When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.
When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?
a. The drain must be compressed after emptying to work properly.
b. The drain must be connected to suction if ordered.
c. The drain is not sutured in place so care is taken to not dislodge it.
d. The suction pulls drainage away from the wound as it re-expands.
ANS: C
The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction. Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.
The nurse identifies which syringe to use when irrigating a patient’s deep wound?
a. 5-mL syringe
b. 10-mL syringe
c. 3-mL syringe
d. 30-mL syringe
ANS: D
A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi.
The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?
a. Stratum germinativum
b. Epidermis
c. Subcutaneous layer
d. Stratum corneum
ANS: C
The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.
The nurse recognizes that the cause of pressure injuries includes which factors? (Select all that apply.)
a. Intensity of the pressure
b. Duration of the pressure
c. Tissue’s ability to tolerate the pressure
d. Person’s age
e. Person’s nutritional status
ANS: A, B, C, D, E
The primary cause of pressure injuries is, as the name suggests, pressure. However, it is more than just pressure; it is the intensity of the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue’s ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.
When discussing stage 3 pressure injuries with the student nurse, which description would the staff nurse include?
a. A pressure injury that involves exposure of bone and connective tissue
b. A pressure injury that does not extend through the fascia
c. A pressure injury that does not include tunneling
d. A partial-thick wound that involves the epidermis
ANS: B
Stage 3 pressure injuries are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure injuries involve exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage 2 pressure injuries are partial-thickness wounds that involve the epidermis and/or dermis.
A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?
a. The nurse asks the UAP to assess the wound.
b. The nurse asks the UAP to report increased wound drainage.
c. The nurse asks the UAP to observe changes in dietary intake.
d. The nurse asks the UAP to change the dressing.
ANS: A
Assessment and evaluation of a patient’s skin and wounds, and the effectiveness of the treatment plan, are a nurse’s responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.
STAGE 1 AND STAGE 2 WOUND DRESSINGS CAN BE DELAGATED TO UAP’S
STAGE 3 AND STAGE 4 WOUNDS MUST BE DONE BY NURSE, THEY INVOLVE PACKING AND THE STERILE TECHNIQUE BECAUSE OF THE TUNNELING AND UNDERMINING OF THE WOUND
how would the normal color of a wound bed present itself?
A. Yellow with scar
B. Red beefy moist
C. Pink dry
D. Scaling
B. Red beefy moist
The wound bed should be beefy red and shiny or moist in appearance.
What are the signs of an infected wound?
A.blue, cold cyanotic
B. redness, warmth, with purulent drainage
C. Sangeinious , warm to touch
D. Serous fluid, cold to touch
B. redness, warmth, with purulent drainage
An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus),
What is Dehiscence?
is the partial or complete separation of the tissue layers during the healing process.
Pt may complain of a popping sensation
Nursing intervention, have the pt splint or use a pillow when they feel the need to cough, sneeze to prevent dehiscence or evisceration
What is Evisceration?
is the total separation of the tissue layers, allowing the protrusion of visceral organs through the incision.
Nursing intervention, have the pt splint or use a pillow , or abdominal binder when they feel the need to cough, sneeze to prevent dehiscence or evisceration
What patients are at risk for Dehiscence and Evisceration?
In addition, obese pt’s coughing, vomiting, or straining puts additional stress on the healing tissue, increasing the risk of dehiscence and evisceration.
What Layers of the full-thickness burns damage?
EPIDERMIS
DERMIS
AND
PART OF SUBCUTANEOUS
Full-thickness burns destroy the epidermis, dermis, and part of the subcutaneous tissue. These severe burns cause the area to be white or brown, charred, and without sensation.
How would a superficial burn present itself?
Burns can be superficial, causing damage to only the epidermis, with resulting pain and erythema.
How would a partial-thickness burn present itself?
Partial-thickness burns destroy the epidermis and part or all of the dermis, causing blistering and pain.
What medical device can most likely cause a pressure injury?
A. Urinal
B. Blood pressure cuff
C. nasal cannula
D. Log roller
C. nasal cannula
Patients who have medical devices (such as oxygen tubing, a nasogastric [NG] tube, oxygen sensor probes, a continuous positive airway pressure [CPAP] mask, or trach ties) are at risk for medical device–related pressure injuries.
What is Mechanical debridement?
Give an example of the technique?
Mechanical debridement is a nonselective form of debridement in that it not only removes the necrotic tissue but also can remove or disturb exposed viable tissue that may be in the wound.
=The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools
-Wet/damp-to-dry dressings usually are saline-moistened dressing materials that are allowed to dry to the wound and are then removed, pulling the surface layer off the wound bed
-Mechanical debridement often is painful for the patient, is harmful to viable tissue, can lead to bleeding and, in the case of wet/damp-to-dry dressings, is labor-intensive.
What is Enzymatic debridement?
-Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal.
-SLOWER THAN MECHANICAL AND SHARP DEBRIDEMENT
-Use of topical agents that are composed of enzymes; Some examples are Santyl, Panafil, and Accuzyme.
-it is selective for nonviable tissue and is quite effective when used appropriately.
