wound care practice Qs - Sheet1

Question 1

1. When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?
2. A local skin infection requiring antibiotics
3. Sensitive skin that requires special bed linen
4. A Stage 3 pressure injury needing the appropriate dressing
5. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

Answer 1

Answer: 4
Rationale: Blanching hyperemia reflects a normal response of the body to restore blood flow to ischemic tissue. Non-blanchable redness would indicate a Stage 1 pressure injury.

Question 2

2. Match the pressure injury stages with the correct definition.
   ___ 1. Stage 1
   ___ 2. Stage 2
   ___ 3. Stage 3
   ___ 4. Stage 4
   ___ 5. Unstageable pressure injury

Answer 2

Answer: 1b, 2a, 3d, 4c, 5e
Rationale: Each stage describes the extent of tissue damage, from nonblanchable erythema (Stage 1) to full-thickness tissue loss (Stage 4). Unstageable pressure injuries are obscured by slough or eschar.

Question 3

3. 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 small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.)
4. Notify the health care provider.
5. Allow the area to be exposed to air until all drainage has stopped.
6. Place several cold packs over the area, protecting the skin around the wound.
7. Cover the area with sterile, saline-soaked towels immediately.
8. Cover the area with sterile gauze and apply an abdominal binder.

Answer 3

Answer: 1, 4
Rationale: The priority is to protect exposed tissues by covering the area with sterile, saline-soaked towels and promptly notifying the healthcare provider. Cold packs and air exposure are inappropriate.

Question 4

4. Place the steps when performing wound irrigation of a large open wound in the correct sequence.
5. Use slow, continuous pressure to irrigate wound.
6. Attach 19-gauge angiocatheter to syringe.
7. Fill syringe with irrigation fluid.
8. Place biohazard bag near bed.
9. Position angiocatheter over wound.

Answer 4

Answer: 4, 3, 2, 5, 1
Rationale: Preparing a clean area (biohazard bag) first ensures safe waste disposal. Proper steps ensure effective irrigation without contamination.

Question 5

5. Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.)
6. Frequent position changes
7. Keeping the buttocks exposed to air at all times
8. Using a large absorbent diaper, changing when saturated
9. Using an incontinence cleaner
10. Applying a moisture barrier ointment

Answer 5

Answer: 1, 4, 5
Rationale: Frequent position changes reduce pressure, and using incontinence cleaners and moisture barriers protects the skin. Keeping skin exposed and relying on saturated diapers is inappropriate.

Question 6

6. Which of the following are measures to reduce tissue damage from shear? (Select all that apply.)
7. Use a transfer device (e.g., transfer board).
8. Have head of bed elevated when transferring patient.
9. Have head of bed flat when repositioning patient.
10. Raise head of bed 60 degrees when patient is positioned supine.
11. Raise head of bed 30 degrees when patient is positioned supine.

Answer 6

Answer: 1, 3, 5
Rationale: Minimizing elevation and using a transfer device reduce friction and shear forces, which can damage tissues.

Question 7

7. 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.)
8. Collection of wound drainage
9. Provision of support to abdominal tissues when coughing or walking
10. Reduction of abdominal swelling
11. Reduction of stress on the abdominal incision
12. Stimulation of peristalsis (return of bowel function) from direct pressure

Answer 7

Answer: 2, 4
Rationale: Binders provide support and reduce stress on the incision. They are not intended for drainage collection, swelling reduction, or peristalsis stimulation.

Question 8

8. Medical adhesives, such as tape securing a wound dressing, cause MARSI. Which of the following interventions reduce the risk for MARSI?
9. Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound.
10. Change dressing only when saturated.
11. Apply adhesive remover.
12. Use Montgomery ties to secure the dressing.
13. Immobilize area of wound.

Answer 8

Answer: 1, 3, 4
Rationale: Gentle tape removal, adhesive removers, and alternatives like Montgomery ties reduce skin damage. Waiting until the dressing is saturated increases risk.

Question 9

9. What is the removal of devitalized tissue from a wound called?
10. Debridement
11. Pressure distribution
12. Negative-pressure wound therapy
13. Sanitization

Answer 9

Answer: 1
Rationale: Debridement removes necrotic tissue to promote healing and prevent infection.

Question 10

10. Which of the following nursing activities apply to an MDRPI? (Select all that apply.)
11. Assess skin under devices every 2 hours.
12. Cushion at risk areas (e.g., ears, nose with foam or protective dressing).
13. Choose correct size of device.
14. Observe for erythema or irritation that conforms to pattern or shape of device.
15. Observe under casts and splints.

Answer 10

Answer: 2, 3, 4, 5
Rationale: Preventing and managing MDRPIs involves using proper-sized devices, cushioning high-risk areas, and monitoring for irritation under all medical devices. Frequent assessment is essential.