Question 1

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

Accepted Answer

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. A

Question 2

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?

Accepted Answer

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. B,D,E,F

Question 3

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity.The nurse consults a

Accepted Answer

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

Question 4

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

Accepted Answer

A)   Monitoring of the wound.
B)   Irrigation of the wound.
C)   Débridement of the wound.
D)   Management of drainage.

Question 5

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

Accepted Answer

A)   Fat.
B)   Carbohydrates.
C)   Protein.
D)   Vitamin E.

Question 6

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

Question 7

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?

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 color.

Question 8

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?

Accepted Answer

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.

Question 9

Which of the following would be the most important piece of assessment data to gather with regard to wound healing?

Accepted Answer

A)   Muscular strength assessment
B)   Sleep assessment
C)   Pulse oximetry assessment
D)   Sensation assessment

Question 10

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?

Accepted Answer

A)   Use a low-air-loss therapy unit.
B)   Consult a dietitian.
C)   Irrigate with hydrogen peroxide.
D)   Utilize hydrogel dressing.

Question 11

The nurse is caring for a patient with a stage IV pressure ulcer.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 12

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

Accepted Answer

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

Question 13

Which nursing observation would indicate that a wound healed by secondary intention?

Accepted Answer

A)   Minimal scar tissue
B)   Minimal loss of tissue function
C)   Permanent dark redness at site
D)   Scarring can be severe.

Question 14

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?

Accepted Answer

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.

Question 15

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?

Accepted Answer

A)   Cotton-tipped applicator
B)   Disposable measuring tape
C)   Sterile gloves
D)   Halogen light

Question 16

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?

Accepted Answer

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.

Question 17

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.

Question 18

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

Accepted Answer

A)   A diet low in calories and fat.
B)   Alteration in level of consciousness.
C)   Shortness of breath.
D)   Muscular pain.

Question 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?

Accepted Answer

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."

Question 20

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

Accepted Answer

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

Exam 93: Skin Integrity and Wound Care