Question 1

What role does protein play in wound healing?

Accepted Answer

A)  Provides fuel for cell energy 
B)  Promotes collagen synthesis and capillary wall integrity 
C)  Promotes epithelialization and collagen formation 
D)  Fibroplasia and angiogenesis 
A)  Provides fuel for cell energy 
B)  Promotes collagen synthesis and capillary wall integrity 
C)  Promotes epithelialization and collagen formation 
D)  Fibroplasia and angiogenesis D

Question 2

Which nutrient has no known role in wound healing?

Accepted Answer

A)  Vitamin A 
B)  Vitamin C 
C)  Vitamin E 
D)  Zinc 
A)  Vitamin A 
B)  Vitamin C 
C)  Vitamin E 
D)  Zinc C

Question 3

The nurse recognizes that skin integrity can be compromised when skin is exposed to body fluids.The greatest risk exists for the patient who has exposure to which one of the following fluids?

Accepted Answer

A)  Urine 
B)  Purulent exudates 
C)  Pancreatic fluids 
D)  Serosanguineous drainage 
A)  Urine 
B)  Purulent exudates 
C)  Pancreatic fluids 
D)  Serosanguineous drainage C

Question 4

A patient has a healing abdominal wound.The wound has minimal exudate and collagen formation.How should the nurse document this wound in the patient's chart?

Accepted Answer

A)  Primary intention 
B)  Inflammatory phase 
C)  Proliferative phase 
D)  Secondary intention 
A)  Primary intention 
B)  Inflammatory phase 
C)  Proliferative phase 
D)  Secondary intention

Question 5

How should the nurse aim to reduce a patient's risk of developing pressure ulcers?

Accepted Answer

A)  Position the patient directly on the trochanter when the patient is lying on his or her side. 
B)  Use a doughnut device for the patient when sitting up. 
C)  Position the patient at a 30-degree lateral turn and limit head elevation to 30 degrees. 
D)  Massage over bony prominences. 
A)  Position the patient directly on the trochanter when the patient is lying on his or her side. 
B)  Use a doughnut device for the patient when sitting up. 
C)  Position the patient at a 30-degree lateral turn and limit head elevation to 30 degrees. 
D)  Massage over bony prominences.

Question 6

The nurse determines that the patient's wound may be infected.In order to perform a quantitative swab for wound culture,which of the following actions should the nurse take?

Accepted Answer

A)  Collect the superficial drainage. 
B)  Collect the culture before cleansing the wound. 
C)  Obtain a culturette tube and use sterile technique. 
D)  Use the same technique as for collecting an anaerobic culture. 
A)  Collect the superficial drainage. 
B)  Collect the culture before cleansing the wound. 
C)  Obtain a culturette tube and use sterile technique. 
D)  Use the same technique as for collecting an anaerobic culture.

Question 7

When using the Braden Scale to predict a patient's pressure sore risk in relation to activity,what score would the nurse use to document for a patient who is confined to a chair?

Accepted Answer

A)  1 
B)  2 
C)  3 
D)  4 
A)  1 
B)  2 
C)  3 
D)  4

Question 8

As a result of which of the following causes do pressure ulcers primarily form?

Accepted Answer

A)  Nitrogen buildup in the underlying tissues 
B)  Prolonged illness or disease 
C)  Pressure in combination with shear and/or friction 
D)  Poor nutrition 
A)  Nitrogen buildup in the underlying tissues 
B)  Prolonged illness or disease 
C)  Pressure in combination with shear and/or friction 
D)  Poor nutrition

Question 9

When turning a patient,the nurse notices a reddened area on the coccyx.Which of the following skin care interventions should the nurse use on this area?

Accepted Answer

A)  Clean the area, dry it, and add a protective moisturizer. 
B)  Apply a diluted hydrogen peroxide and water mixture, and use a heat lamp on the area. 
C)  Soak the area in normal saline solution. 
D)  Wash the area with an astringent, and paint it with povidone-iodine (Betadine). 
A)  Clean the area, dry it, and add a protective moisturizer. 
B)  Apply a diluted hydrogen peroxide and water mixture, and use a heat lamp on the area. 
C)  Soak the area in normal saline solution. 
D)  Wash the area with an astringent, and paint it with povidone-iodine (Betadine).

Question 10

Which of the following nursing entries is most complete in describing a patient's wound?

Accepted Answer

A)  "Wound appears to be healing well. Dressing dry and intact." 
B)  "Wound well approximated with minimal drainage." 
C)  "Drainage size of quarter; wound pink, 4 ´ 4 applied." 
D)  "Incisional edges approximated without redness or drainage; two 4 ´ 4 applied." 
A)  "Wound appears to be healing well. Dressing dry and intact." 
B)  "Wound well approximated with minimal drainage." 
C)  "Drainage size of quarter; wound pink, 4 ´ 4 applied." 
D)  "Incisional edges approximated without redness or drainage; two 4 ´ 4 applied."

Question 11

Which of the following foods would the nurse recommend in order to increase the patient's intake of vitamin A?

Accepted Answer

A)  Poultry, fish, eggs 
B)  Tomatoes, potatoes, fruit juice 
C)  Sweet potatoes, broccoli, liver 
D)  Oysters, fish, legumes 
A)  Poultry, fish, eggs 
B)  Tomatoes, potatoes, fruit juice 
C)  Sweet potatoes, broccoli, liver 
D)  Oysters, fish, legumes

Question 12

The patient has a large,deep wound on the sacral region.The nurse correctly packs the wound by doing which one of the following?

Accepted Answer

A)  Filling two-thirds of the wound cavity 
B)  Leaving saline-soaked folded gauze squares in place 
C)  Putting the dressing in very tightly 
D)  Extending only to the surface of the wound 
A)  Filling two-thirds of the wound cavity 
B)  Leaving saline-soaked folded gauze squares in place 
C)  Putting the dressing in very tightly 
D)  Extending only to the surface of the wound

Question 13

A patient requires wound debridement.The nurse is aware that which of the following statements is correct regarding this procedure?

Accepted Answer

A)  This procedure involves flushing debris from wounds. 
B)  This procedure involves the removal of nonviable necrotic tissue. 
C)  Mechanical methods involve direct surgical removal of the eschar layer of the wound. 
D)  Enzymatic debridement may be implemented independently by the nurse whenever it is required. 
A)  This procedure involves flushing debris from wounds. 
B)  This procedure involves the removal of nonviable necrotic tissue. 
C)  Mechanical methods involve direct surgical removal of the eschar layer of the wound. 
D)  Enzymatic debridement may be implemented independently by the nurse whenever it is required.

Question 14

The patient is brought into the emergency department with a knife wound.The nurse correctly documents the patient's wound as which type?

Accepted Answer

A)  Contusion wound 
B)  Clean wound 
C)  Puncture wound 
D)  Primary intention wound 
A)  Contusion wound 
B)  Clean wound 
C)  Puncture wound 
D)  Primary intention wound

Question 15

The nurse is concerned that the patient's abdominal wound is at risk for dehiscence.Which of the following interventions is the best one to prevent this complication?

Accepted Answer

A)  Administering antibiotics to prevent infection 
B)  Using appropriate sterile technique when changing the dressing 
C)  Keeping sterile towels and extra dressing supplies near the patient's bed 
D)  Placing a pillow over the incision site when the patient is deep breathing or coughing 
A)  Administering antibiotics to prevent infection 
B)  Using appropriate sterile technique when changing the dressing 
C)  Keeping sterile towels and extra dressing supplies near the patient's bed 
D)  Placing a pillow over the incision site when the patient is deep breathing or coughing

Question 16

On changing the patient's dressing,the nurse notes that the wound appears to be granulating.Which one of the following is an appropriate noncytotoxic cleansing agent selected by the nurse?

Accepted Answer

A)  Sterile saline 
B)  Hydrogen peroxide 
C)  Povidone-iodine (Betadine) 
D)  Sodium hypochlorite (Dakin's solution) 
A)  Sterile saline 
B)  Hydrogen peroxide 
C)  Povidone-iodine (Betadine) 
D)  Sodium hypochlorite (Dakin's solution)

Question 17

The nurse notes that the patient's skin is reddened,with a small intact serum-filled blister.How should the nurse classify this stage of ulcer formation?

Accepted Answer

A)  Stage I 
B)  Stage II 
C)  Stage III 
D)  Stage IV 
A)  Stage I 
B)  Stage II 
C)  Stage III 
D)  Stage IV

Question 18

Which of the following is an age-related skin change?

Accepted Answer

A)  Increased collagen 
B)  Increase in size of hypodermis 
C)  Flattening of attachment between dermis and epidermis 
D)  A heightened inflammatory response resulting in increased epithelialization 
A)  Increased collagen 
B)  Increase in size of hypodermis 
C)  Flattening of attachment between dermis and epidermis 
D)  A heightened inflammatory response resulting in increased epithelialization

Question 19

The nurse uses the Braden Scale in the extended care facility to determine the patient's risk for pressure ulcer development.Which score,based on this scale,places the patient at the highest level of risk?

Accepted Answer

A)  <10 
B)  10 to 12 
C)  13 to 14 
D)  15 to 16 
A)  <10 
B)  10 to 12 
C)  13 to 14 
D)  15 to 16

Question 20

The patient is scheduled for a dressing change.When removing the adhesive tape used to secure the dressing,the nurse should lift the edge and hold the tape in which manner?

Accepted Answer

A)  At a 45-degree angle to the skin surface while pulling away from the dressing 
B)  At a right angle to the skin surface while pulling toward the dressing 
C)  At a right angle to the skin surface while pulling away from the dressing 
D)  Parallel to the skin surface while pulling toward the dressing 
A)  At a 45-degree angle to the skin surface while pulling away from the dressing 
B)  At a right angle to the skin surface while pulling toward the dressing 
C)  At a right angle to the skin surface while pulling away from the dressing 
D)  Parallel to the skin surface while pulling toward the dressing

Exam 46: Skin Integrity and Wound Care

What role does protein play in wound healing?

Which nutrient has no known role in wound healing?

The nurse recognizes that skin integrity can be compromised when skin is exposed to body fluids.The greatest risk exists for the patient who has exposure to which one of the following fluids?

A patient has a healing abdominal wound.The wound has minimal exudate and collagen formation.How should the nurse document this wound in the patient's chart?

How should the nurse aim to reduce a patient's risk of developing pressure ulcers?

The nurse determines that the patient's wound may be infected.In order to perform a quantitative swab for wound culture,which of the following actions should the nurse take?

When using the Braden Scale to predict a patient's pressure sore risk in relation to activity,what score would the nurse use to document for a patient who is confined to a chair?

As a result of which of the following causes do pressure ulcers primarily form?

When turning a patient,the nurse notices a reddened area on the coccyx.Which of the following skin care interventions should the nurse use on this area?

Which of the following nursing entries is most complete in describing a patient's wound?

Which of the following foods would the nurse recommend in order to increase the patient's intake of vitamin A?

The patient has a large,deep wound on the sacral region.The nurse correctly packs the wound by doing which one of the following?

A patient requires wound debridement.The nurse is aware that which of the following statements is correct regarding this procedure?

The patient is brought into the emergency department with a knife wound.The nurse correctly documents the patient's wound as which type?

The nurse is concerned that the patient's abdominal wound is at risk for dehiscence.Which of the following interventions is the best one to prevent this complication?

On changing the patient's dressing,the nurse notes that the wound appears to be granulating.Which one of the following is an appropriate noncytotoxic cleansing agent selected by the nurse?

The nurse notes that the patient's skin is reddened,with a small intact serum-filled blister.How should the nurse classify this stage of ulcer formation?

Which of the following is an age-related skin change?

The nurse uses the Braden Scale in the extended care facility to determine the patient's risk for pressure ulcer development.Which score,based on this scale,places the patient at the highest level of risk?

The patient is scheduled for a dressing change.When removing the adhesive tape used to secure the dressing,the nurse should lift the edge and hold the tape in which manner?

Health and Wellness

The Canadian Health Care Delivery System

The Development of Nursing in Canada

Community Health Nursing Practice

Theoretical Foundations of Nursing Practice

Research As a Basis for Practice

Nursing Values and Ethics

Legal Implications in Nursing Practice

Global Health, culture, and Diversity

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Critical Thinking in Nursing Practice

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the Health Care Delivery System

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