Question 1

Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury?

Accepted Answer

A)  Serum total protein level of 4.6 g/dL 
B)  Braden Scale score of 22 
C)  Cetirizine 5 mg PO daily 
D)  Fasting serum glucose level 84 mg/dL 
A)  Serum total protein level of 4.6 g/dL 
B)  Braden Scale score of 22 
C)  Cetirizine 5 mg PO daily 
D)  Fasting serum glucose level 84 mg/dL A

Question 2

Which assessment charting indicates that the wound is healing by primary intention?

Accepted Answer

A)  The 4-inch incision edges are well approximated with intact sutures. 
B)  Ulcerated 3-inch × 1-inch area has thick yellow slough present in the center. 
C)  Incision is 5 inch long × 1 inch deep × 1 inch wide with granulation tissue present. 
D)  Superficial 3-inch × 3-inch abrasion has no active bleeding,drainage or debris. 
A)  The 4-inch incision edges are well approximated with intact sutures. 
B)  Ulcerated 3-inch × 1-inch area has thick yellow slough present in the center. 
C)  Incision is 5 inch long × 1 inch deep × 1 inch wide with granulation tissue present. 
D)  Superficial 3-inch × 3-inch abrasion has no active bleeding,drainage or debris. A

Question 3

The patient has a large red,blistered area on the left hip.Which pressure injury stage will be recorded in the patient's chart?

Accepted Answer

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

Question 4

Which intervention will the nurse use for an abscessed leg wound?

Accepted Answer

A)  Warm water sitz baths 
B)  Cold moist compresses 
C)  Warm moist compresses 
D)  Epsom salt solution soaks 
A)  Warm water sitz baths 
B)  Cold moist compresses 
C)  Warm moist compresses 
D)  Epsom salt solution soaks

Question 5

Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery?

Accepted Answer

A)  Mental status and orientation 
B)  Hourly fluid intake and output 
C)  Lung sounds and pulse oximetry 
D)  Presence of peripheral pedal pulses 
A)  Mental status and orientation 
B)  Hourly fluid intake and output 
C)  Lung sounds and pulse oximetry 
D)  Presence of peripheral pedal pulses

Question 6

The patient just sustained a deep laceration that is bleeding profusely.Which stage of healing describes the current state of the patient's wound?

Accepted Answer

A)  Hemostasis phase 
B)  Proliferative phase 
C)  Inflammation phase 
D)  Remodeling phase 
A)  Hemostasis phase 
B)  Proliferative phase 
C)  Inflammation phase 
D)  Remodeling phase

Question 7

The nurse is caring for a patient with a puncture wound.How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

Accepted Answer

A)  1 year 
B)  3 years 
C)  5 years 
D)  10 years 
A)  1 year 
B)  3 years 
C)  5 years 
D)  10 years

Question 8

The patient's incision is fading to a pale pink following surgery 2 months previously.Which stage of the healing describes the current status of the patient's wound?

Accepted Answer

A)  Hemostasis phase 
B)  Remodeling phase 
C)  Proliferative phase 
D)  Inflammation phase 
A)  Hemostasis phase 
B)  Remodeling phase 
C)  Proliferative phase 
D)  Inflammation phase

Question 9

The patient has a nonblanchable area of redness on the right malleolus.Which pressure injury stage will be recorded in the patient's chart?

Accepted Answer

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

Question 10

The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue.Which term will the nurse use to describe the ulcer in the patient's medical record?

Accepted Answer

A)  Fluctuant 
B)  Indurated 
C)  Macerated 
D)  Unstageable 
A)  Fluctuant 
B)  Indurated 
C)  Macerated 
D)  Unstageable

Question 11

The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.Which term will the nurse use to describe this area?

Accepted Answer

A)  Reactive hyperemia 
B)  Secondary erythema 
C)  Blanchable hyperemia 
D)  Nonblanchable erythema 
A)  Reactive hyperemia 
B)  Secondary erythema 
C)  Blanchable hyperemia 
D)  Nonblanchable erythema

Question 12

Which factor contributes to pressure injury formation when patient's body slides downward to the foot of the bed?

Accepted Answer

A)  Momentum 
B)  Acceleration 
C)  Applied force 
D)  Shearing force 
A)  Momentum 
B)  Acceleration 
C)  Applied force 
D)  Shearing force

Question 13

The patient's sacral pressure injury is open with exposed bone.Which pressure injury stage will be recorded in the patient's chart?

Accepted Answer

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

Question 14

The nurse is caring for a patient with a necrotic wound.Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?

Accepted Answer

A)  Transparent film 
B)  Hydrogel dressing 
C)  Dry nonstick gauze 
D)  Hydrocolloid dressing 
A)  Transparent film 
B)  Hydrogel dressing 
C)  Dry nonstick gauze 
D)  Hydrocolloid dressing

Question 15

The patient's wound has thick creamy yellow drainage present on the dressing.How will the nurse document this finding?

Accepted Answer

A)  Serous drainage 
B)  Purulent drainage 
C)  Sanguineous drainage 
D)  Serosanguineous drainage 
A)  Serous drainage 
B)  Purulent drainage 
C)  Sanguineous drainage 
D)  Serosanguineous drainage

Question 16

How will the nurse obtain a culture of the patient's wound?

Accepted Answer

A)  Obtain a sample from the patient's wound drainage bag. 
B)  Obtain a sample of the drainage around the edge of the wound. 
C)  Obtain a sample of the drainage from the dressing on the wound. 
D)  Gently swab the center of the wound after irrigating with sterile saline. 
A)  Obtain a sample from the patient's wound drainage bag. 
B)  Obtain a sample of the drainage around the edge of the wound. 
C)  Obtain a sample of the drainage from the dressing on the wound. 
D)  Gently swab the center of the wound after irrigating with sterile saline.

Question 17

Which is the first intervention of the nurse for changing the dressing to a painful burn?

Accepted Answer

A)  Administer pain medication 30 minutes beforehand. 
B)  Gently irrigate the wound using sterile normal saline. 
C)  Loosen the tape gently by pressing the skin away from it. 
D)  Observe the wound bed for presence of granulation tissue. 
A)  Administer pain medication 30 minutes beforehand. 
B)  Gently irrigate the wound using sterile normal saline. 
C)  Loosen the tape gently by pressing the skin away from it. 
D)  Observe the wound bed for presence of granulation tissue.

Question 18

Which patient would benefit from soaking in a sitz bath?

Accepted Answer

A)  A patient with an abscessed tooth 
B)  A patient with a fractured right arm 
C)  A patient with painful back muscle spasms 
D)  A patient who just had hemorrhoid surgery 
A)  A patient with an abscessed tooth 
B)  A patient with a fractured right arm 
C)  A patient with painful back muscle spasms 
D)  A patient who just had hemorrhoid surgery

Question 19

The nurse is caring for a patient who has perineal skin breakdown after sitting in wet underclothes for many hours.Which term will be used to document the patient's condition in the medical record?

Accepted Answer

A)  Maceration 
B)  Dehiscence 
C)  Evisceration 
D)  Debridement 
A)  Maceration 
B)  Dehiscence 
C)  Evisceration 
D)  Debridement

Question 20

The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone,tendon,or muscle.Which pressure injury stage will be recorded in the patient's chart?

Accepted Answer

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

Exam 38: Skin Integrity and Wound Care

Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury?

Which assessment charting indicates that the wound is healing by primary intention?

The patient has a large red,blistered area on the left hip.Which pressure injury stage will be recorded in the patient's chart?

Which intervention will the nurse use for an abscessed leg wound?

Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery?

The patient just sustained a deep laceration that is bleeding profusely.Which stage of healing describes the current state of the patient's wound?

The nurse is caring for a patient with a puncture wound.How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

The patient's incision is fading to a pale pink following surgery 2 months previously.Which stage of the healing describes the current status of the patient's wound?

The patient has a nonblanchable area of redness on the right malleolus.Which pressure injury stage will be recorded in the patient's chart?

The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue.Which term will the nurse use to describe the ulcer in the patient's medical record?

The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.Which term will the nurse use to describe this area?

Which factor contributes to pressure injury formation when patient's body slides downward to the foot of the bed?

The patient's sacral pressure injury is open with exposed bone.Which pressure injury stage will be recorded in the patient's chart?

The nurse is caring for a patient with a necrotic wound.Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?

The patient's wound has thick creamy yellow drainage present on the dressing.How will the nurse document this finding?

How will the nurse obtain a culture of the patient's wound?

Which is the first intervention of the nurse for changing the dressing to a painful burn?

Which patient would benefit from soaking in a sitz bath?

The nurse is caring for a patient who has perineal skin breakdown after sitting in wet underclothes for many hours.Which term will be used to document the patient's condition in the medical record?

The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone,tendon,or muscle.Which pressure injury stage will be recorded in the patient's chart?

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