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Skin Integrity and Wound Care

cpeters
Quiz by cpeters, updated more than 1 year ago
cpeters
Created by cpeters almost 6 years ago
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Description

College-Level Nursing Block 3 Quiz on Skin Integrity and Wound Care, created by cpeters on 25/02/2015.

Resource summary

Question 1

Question
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when i reddened area blanches on fingertip touch?
Answer
  • A local skin infection requiring antibiotics
  • Sensitive skin that requires special bed linen.
  • A stage III pressure ulcer needing the appropriate dressing
  • Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

Question 2

Question
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?
Answer
  • Stage I
  • Stage II
  • Stage III
  • Stage IV

Question 3

Question
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
Answer
  • Necrotic tissue
  • Wound drainage
  • Drainage on the dressing
  • Wound after it has first been cleaned with normal saline.

Question 4

Question
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?
Answer
  • Allow the area to be exposed to air until all drainage has stopped.
  • Place several cold packs over the area, protecting the skin around the wound.
  • Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.
  • Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

Question 5

Question
Which description best fits that of serous drainage from a wound?
Answer
  • Fresh bleeding
  • Thick and yellow
  • Clear, watery plasma
  • Beige to brown and foul smelling

Question 6

Question
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?
Answer
  • Binder
  • Ice bag
  • Elastic bandage
  • Absorptive diaper

Question 7

Question
Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?
Answer
  • Keeping the buttocks exposed to air at all times.
  • Using a large absorbent diaper, changing when saturated
  • Using an incontinence cleaner, followed by application of a moisture-barrier ointment
  • Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel.

Question 8

Question
Which of the following describes a hydrocolloid dressing?
Answer
  • A seaweed derivative that is highly absorptive
  • A premoistened gauze placed over a granulating wound
  • A debriding enzyme that is used to remove necrotic tissue
  • A dressing that forms a gel that interacts with the wound surface.

Question 9

Question
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?
Answer
  • Collection of wound drainage
  • Reduction of abdominal swelling
  • Reduction of stress on the abdominal incision
  • Stimulation of peristalsis (return of bowel function) from direct pressure

Question 10

Question
When is an application of a warm compress indicated? (Select all that apply.)
Answer
  • To relieve edema
  • For a patient who is shivering
  • To improve blood flow to an injured part
  • To protect bony prominences from pressure ulcers

Question 11

Question
What is the removal of devitalized tissue from a wound called?
Answer
  • Debridement
  • Pressure reduction
  • Negative pressure wound therapy
  • Sanitization

Question 12

Question
Which of the following is NOT an important dimension to consistently measure to determine wound healing?
Answer
  • Width
  • Length
  • Girth
  • Depth

Question 13

Question
What does the Braden Scale evaluate?
Answer
  • Skin integrity at bony prominences, including any wounds
  • Risk factors that place the patient at risk for the skin breakdown
  • The amount of repositioning that the patient can tolerate
  • The factors that place the patient at risk for poor healing.

Question 14

Question
On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?
Answer
  • Stage II
  • Stage IV
  • Unstageable
  • Suspected deep tissue damage

Question 15

Question
Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. Mr Post is at risk for developing a pressure ulcer on his coccyx because of:
Answer
  • Friction
  • Maceration
  • Shearing force
  • Impaired peripheral circulation

Question 16

Question
Which of the following is not a subscale on the Braden scale for predicting pressure ulcer risk?
Answer
  • Age
  • Activity
  • Moisture
  • Sensory perception

Question 17

Question
Which of these patients has a nutritional risk for pressure ulcer development?
Answer
  • Patient A has an albumin level of 3.5.
  • Patient B has a hemoglobin level within normal limits.
  • Patient C has a protein intake of 0.5 g/kg/day.
  • Patient D has a body weight that is 5% great than his ideal weight.

Question 18

Question
Mr. Perkins has a stage II ulcer of his right heel. What would be the most appropriate treatment for this ulcer?
Answer
  • Apply a heat lamp to the area for 20 minutes
  • Apply hydrocolloid dressing and change it as necessary.
  • Apply a calcium alginate dressing and change when strikethrough is noted.
  • Apply a thick layer of enzymatic ointment to the ulcer and the surrounding skin.

Question 19

Question
An adolescent who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply.)
Answer
  • Extremes in age
  • Impaired circulation
  • Impaired/suppressed immune system
  • Malnutrition
  • Poor wound care

Question 20

Question
A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment findings should the nurse expect? (Select all that apply.)
Answer
  • Increase in incisional pain
  • Fever and chills
  • Reddened wound edges
  • Increase in serosanguineous drainage
  • Decrease in thirst

Question 21

Question
A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? (Select all that apply.)
Answer
  • Stage III pressure ulcer
  • Sutured surgical incision
  • Casted bone fracture
  • Laceration sealed with adhesive
  • Open burn area

Question 22

Question
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client’s surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? (Select all that apply.)
Answer
  • Cover the area with saline-soaked sterile dressings.
  • Apply an abdominal binder snugly around the abdomen.
  • Use sterile gauze to apply gentle pressure to the exposed tissues.
  • Position the client supine with his hips and knees bent.
  • Offer the client a warm beverage, such as herbal tea.

Question 23

Question
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin? (Select all that apply.)
Answer
  • Keep the head of the bed elevated 30 degrees.
  • Massage the client’s bony prominences frequently.
  • Apply cornstarch liberally to the skin after bathing.
  • Have the client sit on a gel cushion when in a chair.
  • Reposition the client at least every 3 hr while in bed.

Question 24

Question
What stage would this pressure ulcer be classified as?
Image:
245ba997-299a-4764-91c5-6072e2ce1d47.jpg
Answer
  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Unstageable

Question 25

Question
What stage would this pressure ulcer be classified as?
Image:
efac8b1c-21da-49bc-8ada-82f1dd6ff57c.jpg
Answer
  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Unstageable

Question 26

Question
What stage would this pressure ulcer be classified as?
Image:
a0fd88b3-137a-4d4b-a96e-c7438cc83f82.jpg
Answer
  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Unstageable

Question 27

Question
What stage would this pressure ulcer be classified as?
Image:
50c156eb-e0a0-4cfc-93d5-53ed9e04f85f.png
Answer
  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Unstageable

Question 28

Question
What stage would this pressure ulcer be classified as?
Image:
86795114-fa2e-4bbe-a2c7-5082ff9e0ba8.jpg
Answer
  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Unstageable
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