Question 1

Which of the following are the two risk assessment tools most commonly used in the United States to evaluate a client's risk for pressure ulcers? Select all that apply.

Accepted Answer

A)  Pressure Ulcer Healing Chart
B)  PUSH tool
C)  Braden scale
D)  Norton scale
E)  Braden Q Scale C,D,E

Question 2

Which of the following would be the most appropriate outcome for the client with a stage 2 pressure ulcer?

Accepted Answer

A)  The ulcer is completely healed with minimal scarring.
B)  The client reports no pain at the site.
C)  A minimal amount of drainage is noted.
D)  The wound bed contains 100% granulated tissue. D

Question 3

While applying a wet-to-dry dressing, how would the nurse explain to the client how this procedure works for promoting healing? A wet-to-dry dressing is a:

Accepted Answer

A)  Method of submerging the wound in water, allowing it to soak before drying the wound bed
B)  Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed
C)  Means of debriding the wound but also removing granulation tissue from the wound
D)  Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue C

Question 4

The nurse documents that the new wound has serosanguineous drainage. How is serosanguineous described?

Accepted Answer

A)  Bloody
B)  Red, watery, clear
C)  Purulent drainage
D)  Straw colored

Question 5

A client hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. There is a pressure area on the client's coccyx measuring 5 *3 cm. The area is covered with 100% eschar. What would the nurse identify this as?

Accepted Answer

A)  Stage 2 pressure ulcer
B)  Stage 3 pressure ulcer
C)  Stage 4 pressure ulcer
D)  Unstageable pressure ulcer

Question 6

The nurse is assessing a client that has an underlying cardiac disease and a draining wound, all of which requires careful monitoring of his fluid balance. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?

Accepted Answer

A)  Draw a circle around the area of drainage on a dressing.
B)  Classify drainage as less or more than the previous drainage.
C)  Weigh the client at the same time each day on the same scale.
D)  Weigh dressings before they are applied and after they are removed.

Question 7

The nurse assesses the surrounding skin of the client's colostomy. The client has been incorrectly applying his ostomy appliance and which caused a wound due to the continuous contact with liquid stool. The nurse notes bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound?

Accepted Answer

A)  Acute, full-thickness, open
B)  Chronic, partial-thickness, closed
C)  Acute, partial-thickness, closed
D)  Chronic, unstageable, open

Question 8

The nurse is preparing to apply cold therapy. Which of the following diagnoses are contraindicated for cold therapy?

Accepted Answer

A)  The client with a bleeding wound
B)  The client with a sprained wrist
C)  The client with an infected wound
D)  The client with a pressure ulcer

Question 9

The nurse is preparing to perform wound care for the client that has a stage 2 pressure ulcer on their right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound?

Accepted Answer

A)  Dry gauze dressing changed twice daily
B)  Nonadherent dressing with daily wound care
C)  Hydrocolloid dressing changed as needed
D)  Wet-to-dry dressings changed three times a day

Question 10

What type of wound can be described as a superficial wound, usually self-inflicted due to excessive scratching or mechanical force?

Accepted Answer

A)  Laceration
B)  Contusion
C)  Excoriation
D)  Incision

Question 11

The nurse assesses assigned clients and determines which client is at highest risk for altered skin integrity?

Accepted Answer

A)  A young adult in traction who has a low-protein diet and dehydration
B)  An older client diagnosed with well-controlled type 2 diabetes
C)  A middle-aged adult with metabolic syndrome taking antihypertensives
D)  An adolescent in bed with influenza, having periods of high fever and diaphoresis

Question 12

The nurse is assessing the client with a wound that is considered chronic. The client asks the nurse to explain the difference between chronic and acute wounds. Which of the following would best describe the primary difference between chronic and acute?

Accepted Answer

A)  Chronic wounds are often full-thickness wounds, but acute wounds are superficial.
B)  Chronic wounds are the result of pressure, but acute wounds result from surgery.
C)  Chronic wounds are usually infected, whereas acute wounds are contaminated.
D)  Chronic wounds exceed the typical healing time, but acute wounds heal readily.

Question 13

The nurse is developing a plan of care for a client who was injured in a motor vehicle accident yesterday. The client is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time?

Accepted Answer

A)  Risk for Infection related to subcutaneous injuries
B)  Risk for Impaired Skin Integrity related to immobility
C)  Impaired Tissue Integrity related to ventilator dependency
D)  Impaired Skin Integrity related to ventilator dependency

Question 14

The nurse is developing a teaching plan for a client that has a surgical incision that has been left open. Which of the following points would the nurse make?

Accepted Answer

A)  The client will need to have twice daily wet to dry dressing changes until the wound is completely healed.
B)  The client will need to start a course of antibiotics for the infection until the wound is completely healed.
C)  The client will have more scar tissue formation than there would be for a wound closed at surgery.
D)  The client should expect to remain hospitalized in an isolation room until the wound is completely healed.

Question 15

The nurse is reviewing a wound care nurse's narrative note that states there is a fistula in the lower abdominal wall as a result of a poorly healing surgical wound. What is a common cause of a fistula?

Accepted Answer

A)  Ischemic pressure to a bony prominence
B)  Diminished venous return to the site
C)  Abscess formation from infection or debris
D)  Abnormal straining over the incisional site

Question 16

The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. There is a notation that states there is an absence of the stratum corneum. Which of the following explains why this is a concern?

Accepted Answer

A)  The stratum corneum provides insulation for temperature regulation.
B)  The stratum corneum promotes strength and elasticity to the skin.
C)  The stratum corneum protects the body against the entry of pathogens.
D)  The stratum corneum produces new skin cells on a continuing basis.

Question 17

Which of the following clients does the nurse recognize as being at greatest risk for pressure ulcers?

Accepted Answer

A)  An infant with skin excoriations in the diaper region
B)  A young adult with diabetes in skeletal traction
C)  A middle-aged adult with quadriplegia
D)  An older adult requiring use of assistive device for ambulation

Question 18

The nurse is assessing the client who presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?

Accepted Answer

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

Question 19

Why is an accurate description of the location of a wound important? Select all that apply.

Accepted Answer

A)  Influences the rate of healing
B)  Determines the appropriate treatment choice
C)  Will affect the frequency of dressing changes
D)  Affects client movement and mobility
E)  Provides cues of wound etiology

Question 20

The nurse is caring for a client with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply?

Accepted Answer

A)  Alginate
B)  Antimicrobial petroleum gauze
C)  Foam dressing
D)  Antimicrobial collagen dressings

Exam 35: Skin Integrity Wound Healing