Question 1

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?

Accepted Answer

A)  Sterile technique.
B)  No-touch technique.
C)  Double bagging of contaminated dressings.
D)  Ability of the caregiver. B

Question 2

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

Accepted Answer

A)  Ineffective tissue perfusion.
B)  Risk for infection.
C)  Imbalanced nutrition: less than body requirements.
D)  Acute pain. A

Question 3

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?

Accepted Answer

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. B

Question 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. )

Accepted Answer

A)  Mobility.
B)  Hyperemia.
C)  Induration.
D)  Blanching.
E)  Temperature of skin.F) Nutritional status.

Question 5

The nurse is caring for a patient who has a stage 4 pressure injury and is awaiting plastic surgery consultation.Which of the following specialty beds would be most appropriate?

Accepted Answer

A)  Standard mattress.
B)  Nonpowered redistribution air mattress.
C)  Low-air-loss therapy unit.
D)  Lateral rotation.

Question 6

The nurse is caring for a patient with a stage 3 pressure injury.The nurse has assigned a nursing diagnosis of Risk for infection.Which intervention would be most important for this patient?

Accepted Answer

A)  Teach the family how to manage the odour associated with the wound.
B)  Discuss with the family how to prepare for care of the patient in the home.
C)  Encourage thorough hand hygiene by all individuals caring for the patient.
D)  Encourage increased quantities of carbohydrates and fats.

Question 7

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. )

Accepted Answer

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.

Question 8

The nurse is admitting an older patient from a nursing home.During the assessment,the nurse notes a shallow open pressure injury without slough on the right heel of the patient.How would this pressure injury be staged?

Accepted Answer

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

Question 9

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure injuries.The nurse has become competent in the care of pressure wounds and recognizes that which of the following is a staged pressure injury that does not require a dressing?

Accepted Answer

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

Question 10

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.What is the major element involved in the development of a pressure injury?

Accepted Answer

A)  Pressure.
B)  Resistance.
C)  Stress.
D)  Weight.

Question 11

On inspection of the patient's wound,the nurse notes that it has a large amount of exudate.Which of the following is an appropriate dressing for the nurse to select?

Accepted Answer

A)  Foam.
B)  Hydrogel.
C)  Hydrocolloid.
D)  Transparent film.

Question 12

The patient in medical-surgical acute care has received a nursing diagnosis of Impaired skin integrity.Which health care provider does the nurse consult?

Accepted Answer

A)  Respiratory therapist.
B)  Registered dietitian.
C)  Chaplain.
D)  Case manager.

Question 13

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a score of 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?

Accepted Answer

A)  12.
B)  13.
C)  20.
D)  23.

Question 14

The nurse is caring for a patient after an open repair of an abdominal aortic aneurysm.The nurse requests an abdominal binder and carefully applies the binder.What is the best explanation for the nurse to use when teaching the patient the reason for the binder?

Accepted Answer

A)  The binder creates pressure over the abdomen.
B)  The binder supports the abdomen.
C)  The binder reduces edema at the surgical site.
D)  The binder secures the dressing in place.

Question 15

The nurse is using the Braden scale to complete a skin risk assessment.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 total Braden scale score?

Accepted Answer

A)  15.
B)  17.
C)  21.
D)  23.

Question 16

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,what is the next best step?

Accepted Answer

A)  Inspecting the wound for bleeding.
B)  Inspecting the wound for foreign bodies.
C)  Determining the size of the wound.
D)  Determining the need for a tetanus antitoxin injection.

Question 17

The nurse is caring for a patient with a stage 4 pressure injury.The nurse assigns which of the following nursing diagnoses?

Accepted Answer

A)  Readiness for enhanced nutrition.
B)  Impaired physical mobility.
C)  Impaired skin integrity.
D)  Chronic pain.

Question 18

The nurse is caring for a patient with a stage 2 pressure injury 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. )

Accepted Answer

A)  Registered dietitian.
B)  Enterostomal and wound care nurse.
C)  Physiotherapist.
D)  Case management personnel.
E)  Chaplain.F) Pharmacist.

Question 19

The nurse is caring for a patient who has undergone a total hysterectomy.Which nursing observation would indicate that the patient was experiencing a complication of wound healing?

Accepted Answer

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 colour.

Question 20

The nurse is caring for a patient in the burn unit.The nurse recalls that this type of wound heals by which process?

Accepted Answer

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

Exam 46: Skin Integrity and Wound Care