FUND CHPT 48 SKIN/WOUND PART 2

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ANS: B

Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The
patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling
discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness
of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.

1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The

nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.

ANS: A

Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development:
pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to
32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and
low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of
something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major
causes of pressure ulcers.

2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and

is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.

ANS: B

The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture
can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can
enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet
is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on
the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin
breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.

3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds.

ANS: C

When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words
"healing stage." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot
return to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer.

The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer

ANS: B

This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The
ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness
over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not
exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without

slough on the right heel of the patient. This pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV.

ANS: D

When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in
assessment—inspection—and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light
sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could
possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of
the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first item used.

6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to

assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light

ANS: C

Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do
not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and
remodeling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are
approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are
shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the
epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges
approximated. Wound closure is delayed until risk of infection is resolved.

DIF: Remember

REF: 1181-1183
OBJ: Discuss the normal process of wound healing.

7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an

example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.

ANS: A

A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and
re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick
resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces
within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur,
moist or dry.

8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist,

it can resurface in _____ day(s).
a. 4
b. 2
c. 1
d. 7

ANS: C

Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown
necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection
and will need to be resolved for the wound to heal.

9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following

in this type of repair?
a. Eschar
b. Slough
c. Granulation
d. Purulent drainage

ANS: D

A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are
approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are
shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the
epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are
approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a
pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes
longer for a wound to heal by secondary intention; thus the chance of infection is greater.

10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals

by

A.Tertiary intention.
B.Secondary intention.
C.Partial-thickness repair.
D. Primary intention.

ANS: B

A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left
open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection
is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin
edges are approximated or closed, and the risk for infection is low. Partial- thickness repair are done on partial-thickness wounds
that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because
the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are
approximated. Wound closure is delayed until the risk of infection is resolved.

11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.

ANS: D

A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes
filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal
quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.

Which nursing observation would indicate that a wound healed by secondary intention?
a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at site
d. Scarring can be severe.

ANS: D

A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth
or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure
on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or
possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and
tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.

13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the

patient was experiencing a complication of wound healing?
a. The incision site has started to itch.
b. The incision site is approximated.
c. The patient has pain at the incision site.
d. The incision has a mass, bluish in color.

ANS: A

occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and
occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has
given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two
organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is
characterized by drainage that is odorous and purulent.

14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?
a. Complaint by patient that something has given way
b. Protrusion of visceral organs through a wound opening
c. Chronic drainage of fluid through the incision site
d. Drainage that is odorous and purulent

ANS: A

Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is
probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it
reflects not only what the patient has ingested, but also what the body has absorbed, digested, and metabolized. Measurement of
creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major
electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and
transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty
acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing.

15. A patient has developed a decubitus ulcer. What laboratory data would be important to gather?
a. Serum albumin
b. Creatine kinase
c. Vitamin E
d. Potassium

ANS: C

Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of
oxygenated blood is critical in wound healing. Blood flow through the pulmonary capillaries provides red blood cells for oxygen
attachment. Oxygen diffuses from the alveoli into the pulmonary blood; most of the oxygen attaches to hemoglobin molecules
within the red blood cells. Red blood cells carry oxygenated hemoglobin molecules through the left side of the heart and out to the
peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues. Pulse oximetry measures the oxygen
saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not
provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of
cognitive function, does not provide any data with regard to wound healing.

16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing?
a. Muscular strength assessment
b. Sleep assessment
c. Pulse oximetry assessment
d. Sensation assessment

ANS: A

The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a
life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should
complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and
laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and
receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status
and on any new orders.

17. The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and

observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
a. Complete the head-to-toe assessment, and include current treatment, vital signs,
and laboratory results.
b. Notify the charge nurse about the change in status and the potential for infection.
c. Notify the physician by utilizing Situation, Background, Assessment, and
Recommendation (SBAR).
d. Notify the wound care nurse about the change in status and the potential for
infection.

ANS: C

Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing
depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of
fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased
amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.

18. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a

meal plan that includes increased
a. Fat.
b. Carbohydrates.
c. Protein.
d. Vitamin E.

ANS: C

The patient's psychological response to any wound is part of the nurse's assessment. Body image changes can influence
self-concept. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and
temporary or permanent prosthetic devices. The wound is odorous, and a drain is in place. The patient who is asking for a bath and
change in linens gives you a clue that he or she may be concerned about the smell in the room. The patient stating that he or she
wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that
indicate progress along the health journey.

19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is

currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of
the following?
a. "I think I will be ready to go home early next week."
b. "I am so weak and tired, I want to feel better."
c. "I am ready for my bath and linen change as soon as possible."
d. "I am hoping there will be something good for dinner tonight."

ANS: A

After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a
laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any
bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size
of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound
is caused by a dirty penetrating object, determine the need for a tetanus vaccination.

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the

patient is stable, the next best step is to
a. Inspect the wound for bleeding.
b. Inspect the wound for foreign bodies.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.

ANS: B

Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and
changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and
avoiding the accidental removal of the drain during the procedure.

21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing.

Which of these actions should the nurse take first?
a. Don sterile gloves.
b. Provide analgesic medications as ordered.
c. Avoid accidentally removing the drain.
d. Gather supplies.

ANS: B

Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden
decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The hea care
lth
provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for
communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.

22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a

sudden decrease in drainage. What would be the nurse's next best step?
a. Remove the drain; a drain is no longer needed.
b. Call the physician; a blockage is present in the tubing.
c. Call the charge nurse to look at the drain.
d. As long as the evacuator is compressed, do nothing.

ANS: B

A low-air-loss therapy unit is utilized for stage IV pressure ulcers and when prevention or treatment of skin breakdown is needed. If
the patient has a stage III or stage IV ulcer or a postoperative myocutaneous flap, the low-air-loss therapy unit wouldbe an
appropriate selection. A static air mattress or nonpowered redistribution is utilized for the patient at high risk for skin breakdown. A
standard mattress is utilized for an individual who does not have actual or potential altered or impair skin integrity. Lateral rotation
is used for treatment and prevention of pulmonary complications associated with mobility.

23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following

specialty beds would be most appropriate?
a. Standard mattress
b. Nonpowered redistribution air mattress
c. Low-air-loss therapy unit
d. Lateral rotation

ANS: C

Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of
infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the
phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and
healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and
reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.

24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in

caring for this patient includes
a. Monitoring of the wound.
b. Irrigation of the wound.
c. Débridement of the wound.
d. Management of drainage.

ANS: C

Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue.
Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process
and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a
low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all
orders that would be appropriate.

25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following

orders would the nurse question?
a. Use a low-air-loss therapy unit.
b. Consult a dietitian.
c. Irrigate with hydrogen peroxide.
d. Utilize hydrogel dressing.

ANS: A

The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and
tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a binasal
cannula and the nares. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could
influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part of a skin assessment.

26. The nurse is completing an assessment of the skin's integrity, which includes
a. Pressure points.
b. All pulses.
c. Breath sounds.
d. Bowel sounds.

ANS: C

With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks
occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is

27. The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is

rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem
with friction and shear. What would be the patient's Braden scale total score?
a. 15
b. 17
c. 20
d. 23

ANS: B

Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in
turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the
chair. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or
her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not
influence the patient's ability to increase mobility.

28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness

and ability to increase mobility, which intervention is most important for the nurse to complete?
a. Encourage the patient to sit up in the chair.
b. Provide analgesic medication as ordered.
c. Explain the risks of immobility to the patient.
d. Turn the patient every 3 hours while in bed.

ANS: C

After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of
Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that
could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the
nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.

29. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses?
a. Readiness for enhanced nutrition
b. Impaired physical mobility
c. Impaired skin integrity
d. Chronic pain

ANS: A

The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue
damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain,
and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing
diagnosis.

30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis

would the nurse assign?
a. Ineffective tissue perfusion
b. Risk for infection
c. Imbalanced nutrition: less than body requirements
d. Acute pain

C

The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and
food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does not
relate to the risk of infection. If the patient will be discharged before the wound is healed, the family will certainly need education
on how to care for the patient. Teaching the family how to manage the odor associated with a wound is certainly important, but
these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process.

31. The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection.

Which intervention would be most important for this patient?
a. Teach the family how to manage the odor associated with the wound.
b. Discuss with the family how to prepare for care of the patient in the home.
c. Encourage thorough handwashing of all individuals caring for the patient.
d. Encourage increased quantities of carbohydrates and fats.

ANS: B

Assessment and a plan for the patient to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote
wound healing. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for
the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can

32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a
a. Respiratory therapist.
b. Registered dietitian.
c. Chaplain.
d. Case manager.

ANS: C

Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for
infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an
increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to
communicate the signs and symptoms of infection; also, this is an intervention, not a goal for this diagnosis. It is important for the
patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are interventions,
not goals or outcomes for this nursing diagnosis.

33. The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient

is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for
this patient?
a. The patient's family will demonstrate specific care of the wound site.
b. The patient will state what to look for with regard to an infection.
c. The patient will remain free of an increase in temperature and of odorous or
purulent drainage from the wound.
d. The patient's family members will wash their hands when visiting the patient.

Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the
treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additional trauma.
The skin already has impaired integrity owing to the surgical procedure, and because of this has been at risk for infection since the
surgical procedure was performed. This patient is of childbearing age and has had a child. Additional needs for nutrition are present
during pregnancy and breastfeeding, but this is an established nursing diagnosis. Data are insufficient to support the nursing
diagnosis of Imbalanced nutrition.

34. The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat

to treat this condition, and the nurse is providing this treatment. This patient is at risk for
a. Infection.
b. Impaired skin integrity.
c. Trauma.
d. Imbalanced nutrition.

ANS: B

Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles
regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required for application.
The caregiver can use the same no touch technique for dressing changes that is used for changing surface dressings without
touching the wound or the surface that might come in contact with the wound. Double bagging is required for the disposal of
contaminated dressings. The dressings go in a bag, which is fastened and then placed in the household trash. The ability of the
caregiver certainly is a component of the success of home treatment, but it does not influence the cost of supplies.

35. The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with

the caregiver. Which intervention assists in managing the expenses associated with long-term wound care?
a. Sterile technique
b. Clean dressings and no touch technique
c. Double bagging of contaminated dressings
d. Ability of the caregiver

ANS: A

Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the
skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to
keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other
alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of
care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this
does not provide the initial defense for skin breakdown.

36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin

impairment. Which initial interventions should the nurse select to decrease this risk?
a. Gentle cleaners and thorough drying of the skin
b. Absorbent pads and garments
c. Positioning with use of pillows
d. Therapeutic beds and mattresses

ANS: C

When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be
individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an
air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.

37. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this

intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?
a. At least 3 hours
b. Not longer than 30 minutes
c. Less than 2 hours
d. As long as the patient remains comfortable

ANS: C

When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging
the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a
30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer
development from shearing forces.

38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient.

What is the best method for repositioning the patient?
a. Obtain assistance and use the drawsheet to place the patient into the new position.
b. Place the patient in a 30-degree supine position.
c. Utilize a transfer sliding board and assistance to slide the patient into the new
position.
d. Elevate the head of the bed 45 degrees.

ANS: A

Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows
visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the
presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydro
colloid,
hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel calcium
,
alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a
dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is
used, but this is an unstaged ulcer.

39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become

competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage
a. I.
b. II.
c. III.
d. IV.

ANS: B

Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the
patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do
not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room ca actually
n
increase a patient's anxiety.

40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What

should the nurse do to decrease the patient's anxiety?
a. Tell the patient to close his eyes.
b. Explain the procedure.
c. Turn on the television.
d. Ask the family to leave the room.

ANS: C

Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction
from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least
to the most contaminated area.

41. The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included?
a. Allowing the solution to flow from the most contaminated to the least

contaminated
Scrubbing vigorously when applying solutions to the skin
Cleansing in a direction from the least contaminated area
Utilizing clean gauge and clean gloves to cleanse a site

b.
c.
d.

ANS: C

Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction
from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least
to the most contaminated area.

ANS: C

Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction
from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least
to the most contaminated area.

43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the

procedure, which intervention should the nurse implement?
a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot.

43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the

procedure, which intervention should the nurse implement?
a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot.

ANS: D

The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score
for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.

44. The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission.

The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign
that the risk for skin breakdown is decreasing?
a. 12
b. 13
c. 20
d. 23

ANS: A, B, C, D

A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal
or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility
of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure
ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in
obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need
associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care
multidisciplinary team, unless a special need arises.

1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a

multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in
the consults? (Select all that apply.)
a. Registered dietitian
b. Enterostomal and wound care nurse
c. Physical therapist
d. Case management personnel
e. Chaplain
f. Pharmacist

ANS: A, C, D, F

Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are
critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization,
and decreases the production of proinflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects
of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing.

2. The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing

wound healing? (Select all that apply.)
a. Nutrition
b. Evisceration
c. Tissue perfusion
d. Infection
e. Hemorrhage
f. Age

ANS: A, B, C, D

Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient
is able to feel heat or cold and is mobile, he can protect himself by withdrawing from the source. Knowing toileting habits and any
potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin
breakdown. Knowing whether the patient has problems with mobility such as pain will alert the nurse to any potential for decreased
movement and increased risk for skin breakdown. Medications and falling are safety risk questions.

3. The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in

a skin integrity assessment? (Select all that apply.)
a. "Can you easily change your position?"
b. "Do you have sensitivity to heat or cold?"
c. "How often do you need to use the toilet?"
d. "Is movement painful?"
e. "What medications do you take?"
f. "Have you ever fallen?"

4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment?

(Select all that apply.)
a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status

4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment?

(Select all that apply.)
a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status

ANS: A, B, C, D

Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions,
edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions
with a sterile dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of
underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be
made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be
clean, and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can interfere with
wound healing.

5. The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's

responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.)
a. Inspecting the skin for abrasions and edema
b. Covering exposed wounds
c. Assessing condition of current dressings
d. Assessing the skin at underlying areas for circulatory impairment
e. Marking the sites of all abrasions
f. Cleansing the area with hydrogen peroxide

ANS: B, D, E, F

Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore
skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtain information regarding
the experience, but these are not actual measurable outcomes.

6. The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity.

Which of the following outcomes when met indicate progression toward goals? (Select all that apply.)
a. Ask whether patient's expectations are being met.
b. Prevent injury to the skin and tissues.
c. Obtain the patient's perception of interventions.
d. Reduce injury to the skin.
e. Reduce injury to the underlying tissues.
f. Restore skin integrity.

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