Wound Assessment

Question 1

An elderly patient, who has recently had a stroke, is assessed by the nurse as having a reddened area over the coccyx. To prevent this from progressing the nurse decides to:

Answer 1

• Apply barrier cream.
• 2 hourly turns.
• No wrinkles under the patient.
• Pressure cushions
• Air mattress.

Question 2

The tissue surfaces of an incision that are brought together are described as:

Answer 2

• Little tissue loss primary intention.

- Approximated (?).

Question 3

There are several instruments for assessing patients who are at risk of developing a pressure injury. The Braden Scale is commonly used. What risk factors are assessed using the Braden Scale?

Answer 3

• Sensory perception.
• Moisture.
• Activity.
• Mobility.
• Nutrition.
• Friction.
• Shear.

Question 4

The haemostasis phase of wound healing is characterised by:

Answer 4

Constriction of blood vessels and clot formation.

Question 5

The nurse observes that the client has a pressure injury on their right heel. There is full thickness loss of the dermis. The nurse can see subcutaneous fat, but no muscle or bone. Classify the stage of the pressure injury as:

Answer 5

Stage 3.

Question 6

The nurse uses a surgical aseptic technique when:

Answer 6

An invasive device is used (such as a catheter).