Question 1

ATI - Wound Care Module A nurse is documenting data about a deep necrotic wound on a patient's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. The nurse should document this type of necrotic tissue as: A. Fibrin B. Slough C. Gangrene D. Eschar

Accepted Answer

B. Slough Rationale: Slough is stringy and whitish, and/or tan necrotic tissue that is firmly attached to the wound bed. This is the correct term for the tissue the nurse has observed

Question 2

ATI - Wound Care Module A nurse is caring for a patient with a stage IV sacral pressure ulcer for which the provider has prescribed mechanical debridement. Which of the following should the nurse plan for this patient? A. Placing a transparent dressing over the ulcer. B. Applying larvae to the wound bed. C. Changing dressings using the wet-to-dry method. D. Using a topical enzyme solution in the wound's base.

Accepted Answer

C. Changing dressings using the wet-to-dry method. Rationale: A wet-to-dry saline dressing provides mechanical debridement when it is removed at the next dressing change. It is a common method of mechanical debridement.

Question 3

ATI - Wound Care Module A nurse is caring for a patient who has developed a stage I pressure ulcer in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the ulcer? A. Zinc oxide B. Nystatin C. Papain-urea D. Polymyxin B

Accepted Answer

A. Zinc oxide Rationale: Barrier creams and ointments are used for patients prone to skin breakdown from pressure, shear, or incontinence. They are intended for prevention and for resolving new-onset problems, such as a stage I pressure ulcer.

Question 4

ATI - Wound Care Module A nurse is caring for a patient who is admitted with multiple wounds in a motor-vehicle crash. Understanding the patient's specific needs during this initial stage of wound healing, the nurse should incorporate which of the following into the patient's plan of care to prevent a prolongation of this phase? A. Leave non-bleeding wounds to the air. B. Administer 325 mg aspirin PO as needed. C. Initiate mechanical debridement. D. Apply oxygen at 2 L/min via nasal cannula.

Accepted Answer

D. Apply oxygen at 2 L/min via nasal cannula. Rationale: Following an acute injury, the body responds by increasing perfusion to the location of the injury during the inflammatory phase of wound healing. The purpose of this increased blood supply to the wounds is to transport the oxygen and nutrients essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in patients who have a lack of oxygen or poor perfusion.

Question 5

ATI - Wound Care Module A nurse is caring for a patient who has multiple sclerosis and has a chronic non-healing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? A. Tricyclic antidepressants B. Corticosteroids C. Beta Blockers D. Anticholinergics

Accepted Answer

B. Corticosteroids Rationale: Corticosteroids suppress the immune system and therefore can delay wound healing.

Question 6

ATI - Wound Care Module A patient who has a full-thickness wound continues to experience considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following dressings should the nurse select to help minimize the pain of dressing changes? A. Wet-to-dry B. Antimicrobial C. Gauze D. Hydrogel

Accepted Answer

D. Hydrogel Rationale: In general, keeping some moisture within a wound reduces pain. Hydrogel dressing work by maintaining a most wound environment, so they are a good choice for helping to reduce the pain associated with dressing changes.

Question 7

ATI - Wound Care Module A nurse is caring for a patient who has a heavily draining wound that continues to show evidence of bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis? A. Transparent B. Hydrofiber C. Alignate D. Biologic

Accepted Answer

C. Alignate Rationale: Alignate dressings help establish hemostasis while providing a moist environment for healing and good absorption of exudate. They do not adhere to the wound; therefore, removal is unlikely to cause further bleeding.

Question 8

ATI - Wound Care Module A nurse is assessing a pressure ulcer over the patient's right heel area observes a deep crater with no eschar or slough and no exposed muscle or bone. The nurse should document this patient has a pressure ulcer that is: A. unstageable. B. a suspected deep tissue injury. C. stage IV. D. sage III.

Accepted Answer

D. stage III. Rationale: A stage III pressure ulcer has full-thickness loss appearing as a deep crater, without exposed muscle or bone. There may or may not be slough. This patient's wound fits this description.

Question 9

ATI - Wound Care Module A nurse is documenting data about a healing wound on a patient's lower leg. The predominant exudate in the wound is water in consistency and light red in color. The nurse should document this exudate as: A. serosanguineous. B. sanguineous. C. serous. D. purulent.

Accepted Answer

A. serosanguineous. Rationale: This exudate is serosanguineous, which is thin and water in consistency and pink to light red in color.

Question 10

ATI (Fundamentals Book) - Chapter 55 An adolescent client who has diabetes mellitus is 2 days postopeative following an appendectomy. The client is tolerating a regular diet well. He was ambulated successfully around the unit with assistance and requests pain medication q6 to 8h while reporting pain at a 2 on a scale of 0 to 10 after the medication is given. His incision is approximated and free of redness with scant serous drainage noted on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply) ``` A. Extremes in age B. Impaired ciruculation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care such as breaches in aseptic techique ```

Accepted Answer

B. Impaired ciruculation C. Impaired/suppressed immune system Rationale: Diabetes mellitus places tihs client at risk for impaired circulation and immune system function. The client is not in either extreme of the age spectrum, and there is no indication that he is malnourished or that there have been any breaches in aseptic technique during wound care.

Question 11

ATI (Fundamentals Book) - Chapter 55 An entry in a client's chart states the wound drainage is "sanguineous." that means it is A. watery in appearance. B. green-tinged yellow C. bright-red D. foul-smelling.

Accepted Answer

C. bright-red Rationale: Sanguinous drainage is bright red and the result of active bleeding. A watery appearance is characteristic of serous or serosanguineous drainage. Green-tinged or yellow and foul smelling are characteristics of purulent drainage.

Question 12

ATI (Fundamentals Book) - Chapter 55 Which of the folliwng is an exambple of a wound or injury healing by secondary intention? A. An open burn area B. A bone fracture that is casted C. A sprained ankle D. A sutured surgical incision

Accepted Answer

A. An open burn area Rationale: A burn has loss of tissue, and the skin edges are not together. A fractured bone and sprained ankle are injuries to underlying structures and do not require healing of the skin. A sutured surgical incision heals by primary intention.

Question 13

ATI (Fundamentals Book) - Chapter 55 Scenario: An older adult woman is 6 days postoperative following surgery for a bowel obstruction. During the last 24 hr, she has reported nausea, and she vomitted small amounts of clear liquid three times in the last 8 hr. Her vital signs are stable. Currently, her incision is well approximated and free of redness, tenderness , and swelling Which of the following findings would indicate development of a wound infection? A. Decreased pulse rate B. Increased pain C. Decreased WBC Count D. Increased thirst

Accepted Answer

B. Increased pain Rationale: An increase in incisional pain is a sign of possible wound infection. With infection, the pulse rate and WBC count increase. Increased thirst has many possible causes and does not necessarily indicate an infectious process.

Question 14

ATI (Fundamentals Book) - Chapter 55 The nurse enters the room and finds the client's wound separated with viscera protruding. Which of the following nursing interventions are appropriate? (Select all that apply) ``` A. Repack the wound. B. Call for help. C. Assist the client to a chair. D. Cover the wound with a sterile dressing moistened with 0.9% sodium chloride. E. Stay with the client. ```

Accepted Answer

B. Call for help. D. Cover the wound with a sterile dressing moistened with 0.9% sodium chloride. E. Stay with the client. Rationale: It is appropriate for the nurse to call for help, cover the wound with a sterile dressing moistened with 0.9% sodium chloride, and stay with the client. The nurse should not attempt to reinsert the organs or repack the wound. The nurse should have the client lie supine with her hips and knees bent.

Question 15

ATI (Fundamentals Book) - Chapter 55 Scenario: An older adult client who has diabetes mellitus must now use a wheelchair after a cerebrovascular accident (CVA) 2 years ago that affected her right side. She does not respond to pain on the right side of her body. Her fluid and food intake is good, but she needs help with eating. Which of the following risk factors for developing pressure ulcers does this client have? A. Dehydration B. Limited mobility C. Nutritional impairment D. Incontinence

Accepted Answer

B. Limited mobility Rationale: The client's limited mobility as a result of the CVA puts her at risk for skin breakdown. She is well-hydrated and nourished, and there are no data to inidcate that she has urinary or fecal incontinence

Question 16

ATI (Fundamentals Book) - Chapter 55 Which of the following can the nurse do to prevent skin breakdown? A. Massage the client's bony prominences frequently. B. Keep the client in high-fowler's position while in bed. C. Have the client sit on a donut-shaped cushion. D. Encourage repositioning q15 min while the client is in the wheelchair.

Accepted Answer

D. Encourage repositioning q15 min while the client is in the wheelchair. Rationale: It is essential to encourage and help the client alter her position q15 min while seated to prevented a sustained pressure on any skin areas. While in bed, the head of the client's bed should be elevated no more than 30° to prevent skin breakdown from shearing forces in the sacral area. Donut-shaped cushions increase pressure on the sacral area. A gel foam or air cushion would be a better choice.

Question 17

ATI (Fundamentals Book) - Chapter 55 Which of the following statements describes a stage III pressure ulcer? A. The skin is reddeed and does not blanch with pressure B. The ulcer is an abrasion or a blister. C. The bone is exposed at the center of the ulcer. D. The ulcer extends past the subcutaneous tissue to the muscle.

Accepted Answer

D. The ulcer extends past the subcutaneous tissue to the muscle. Rationale: A stage III ulcer may extend past all layers of the skin and subcutaneous tissue to the muscle. Reddened skin that does not blanch is characteristic of stage I. An abrasion or a blister is seen with stage II. Exposed bone is characteristic of stage IV.

Question 18

My Nursing Lab - Submod 2.12 Wound Care Which of the following is an example of a chronic wound? A client: A. With a hemovac drain insertion at a surgical site. B. Who fell and suffered an open wound to the knee C. Who sustained a break in the skin while shaving. D. With a stage III pressure ulcer

Accepted Answer

D. With a stage III pressure ulcer Rationale: Expected time of healing for a chronic wound is weeks or months

Question 19

My Nursing Lab - Submod 2.12 Wound Care The LPN observed the physical therapy aid getting a client out of bed and noticed that the client sustained an unintentional scraping of the superficial layer of the skin. He or she informs the primary nurse and documents correctly as a(n): A. Crushing wound B. Puncture C. Penetrating wound D. Abrasion

Accepted Answer

D. Abrasion Rationale: An abrasion is a scrape of the superficial layer of the skin

Question 20

My Nursing Lab - Submod 2.12 Wound Care The nurse examines the client admitted with an open wound and finds the wound has eroded the subcutaneous tissue down to the muscle. This wound is correctly documented as: A. Superficial B. Superficial partial thickness C. Partial thickness D. Full thickness

Accepted Answer

D. Full thickness Rationale: Full thickness wounds are those that erode the subcutaneous tissue down to the muscle.

Unit XVI Concepts of Promoting Skin Integrity in Client Centered Care Flashcards

Notes Cards are from the following chapters: Chapter 24 (Berman Book) Chapter 24 (Berman WkBk) Chapter 55 (ATI Fundamentals Book)

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Unit XVI Concepts of Promoting Skin Integrity in Client Centered Care Flashcards

Notes Cards are from the following chapters: Chapter 24 (Berman Book) Chapter 24 (Berman WkBk) Chapter 55 (ATI Fundamentals Book)

Brainscape's Knowledge Genome^TM