Chapter 46 Skin Integrity and Wound Care Potter et al Canadian Fundamentals of Nursing, 6t, Exams of Nursing

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Chapter 46 Skin Integrity and Wound

Care Potter et al Canadian

Fundamentals of Nursing, 6th Edition

Test Bank

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure injuries. The nurse recognizes that the risk factors that predispose a patient to pressure injury development include which of the following? a. A diet low in calories and fat. b. Alteration in level of consciousness. c. Shortness of breath. d. Muscular pain. - ANS: Alteration in level of consciousness. 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? - ANS: Pressure Which nursing observation would indicate that the patient was at risk for pressure injury formation? - ANS: The patient has fecal incontinence. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage 3 pressure injury. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this pressure injury? - ANS: Healing stage 3 pressure injury 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? - ANS: Stage 2.

6. 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 a pressure injury on this patient? - ANS: Halogen light.

7. The nurse is caring for a patient with a stage 4 pressure injury. The nurse recalls that a pressure injury takes time to heal and that the healing process is an example of which of the following? - ANS: Full- thickness wound repair.
8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in how long? - ANS: 4 days.
9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? - ANS: Granulation.
10. The nurse is caring for a patient who has undergone a laparoscopic appendectomy. The nurse recalls that this type of wound heals by which process? - ANS: Primary intention.
11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by which process? - ANS: Secondary intention.
12. Which nursing observation would indicate that a wound healed by secondary intention? - ANS: Scarring can be severe.
13. 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? - ANS: The incision has a mass, bluish in colour.
14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? - ANS: Complaint by patient that something has given way.
15. A patient has developed a pressure injury. What laboratory data would be important to gather? - ANS: Serum albumin level.
16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing? - ANS: Pulse oximetry assessment.

17. The nurse is caring for a patient with a healing stage 3 pressure injury. Upon entering the room, the nurse notices an odour and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? - ANS: Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results.
18. The nurse is collaborating with the dietitian in treatment of a patient with a stage 3 pressure injury. After the collaboration, the nurse orders a meal plan that includes increased levels of what? - ANS: Protein
19. The nurse is completing an assessment on an individual who has a stage 4 pressure injury. The wound is malodorous, and a drain is currently in place. The nurse determines that the patient is experiencing problems with self-concept when the patient states which of the following? - ANS: "I am ready for my bath and linen change as soon as possible."
20. 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? - ANS: Inspect the wound for bleeding.
21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? - ANS: Provide analgesic medications as ordered.
22. 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?

• ANS: Call the physician; a blockage is present in the tubing.

23. 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? - ANS: Nonpowered redistribution air mattress.
24. The nurse is caring for a patient with a pressure injury on the left hip. The pressure injury is black. The nurse recognizes that the next step in caring for this patient includes which of the following? - ANS: Debridement of the wound.

25. The nurse is caring for a patient with a healing stage 3 pressure injury. The wound is clean and granulating. Which of the following orders would the nurse question? - ANS: Irrigate with hydrogen peroxide.
26. The nurse is completing an assessment of the skin's integrity, which includes which of the following?

• ANS: Pressure points.

27. 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 Braden scale total score? - ANS: 21.
28. The nurse is caring for a patient with a stage 4 pressure injury. The nurse assigns which of the following nursing diagnoses? - ANS: Impaired skin integrity.
29. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? - ANS: Ineffective tissue perfusion.
30. 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? - ANS: Encourage thorough hand hygiene of all individuals caring for the patient.
31. The patient in medical-surgical acute care has received a nursing diagnosis of Impaired skin integrity. Which health care provider does the nurse consult? - ANS: Registered dietitian.
32. The nurse is caring for a patient with a stage 2 pressure injury 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? - ANS: The patient will remain free of an increase in temperature and of malodorous or purulent drainage from the wound.
33. 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? - ANS: Foam.

34. 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? - ANS: No-touch technique.
35. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? - ANS: Gentle cleaners and thorough drying of the skin.
36. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? - ANS: Less than 2 hours.
37. 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? - ANS: Stage 1.
38. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? - ANS: Explain the procedure.
39. The nurse is cleansing a wound site. As the nurse is doing so, what intervention should be included? - ANS: Cleansing in a direction from the least contaminated area.
40. The nurse is caring for a patient after an open abdominal aortic aneurysm repair. 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? - ANS: The binder supports the abdomen.
41. The nurse determines that the patient's wound may be infected. In order to perform a quantitative swab for wound culture, which of the following actions should the nurse take? - ANS: Obtain a Culturette tube and use sterile technique.
42. The patient has 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?

• ANS: 23.

43. The nurse is caring for a patient with potential skin breakdown. Which of the following components would the nurse include in the skin assessment? - ANS: Hyperemia, induration, blanching, and temperature of skin.
44. The student nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nursing instructor asks the student what the nursing responsibilities and activities will be before applying the bandage and binder. The nursing instructor will provide further instruction to the student if the student states that the nurse will need to do which of the following? - ANS: Cleanse the area with hydrogen peroxide. When repositioning an immobile patient, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, which indicates which of the following? - ANS: Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area. Which type of pressure injury consists of an observable pressure-related alteration of intact skin that may show changes in skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), or sensation (pain, itching) in comparison with an adjacent or opposite area on the body? - ANS: Stage I. When a wound specimen is obtained for culture to determine whether infection is present, the specimen should be taken from which of the following? - ANS: The wound after it has first been cleansed with normal saline. Postoperatively, a patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the nurse sees that the sutures are open and that pieces of small bowel are visible at the bottom of the now opened wound. What is the correct intervention? - ANS: Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. Serous drainage from a wound is defined as which of the following? - ANS: Clear, watery plasma. Which of the following is not a risk factor for skin breakdown? - ANS: Hearing status.

Which of the following interventions is most appropriate in managing fecal and urinary incontinence in a patient? - ANS: Which of the following interventions is most appropriate in managing fecal and urinary incontinence in a patient? Which of the following is the most effective intervention for problems with skin integrity? - ANS: Prevention strategies. Placement of a binder around a surgical patient with a new abdominal wound is indicated for which of the following? - ANS: Reduction of stress on the abdominal incision. When the skin and subcutaneous layers adhere to the surface of the bed, and the layers of muscle and the bones slide in the direction of body movement, this is known as which of the following? - ANS: shear The nurse observes partial-thickness skin loss involving a patient's epidermis and possibly the dermis. What stage of injury will the nurse document? - ANS: stage II Wound healing has three phases. The nurse observes granulation tissue in a patient's pressure ulcer. What phase of wound healing is represented by granulation tissue? - ANS: Proliferative phase. At what time is the risk of hemorrhage the greatest for surgical wounds? - ANS: During the first 24 to 48 hours after surgery. The autolytic, mechanical, chemical, and surgical methods that are often used during wound management are all methods of accomplishing what? - ANS: Wound debridement. What risk factors are assessed on the Braden Scale for pressure injury risk? - ANS: Sensory perception, moisture, activity, mobility, nutrition, friction, and shear. A 40-year-old patient recently became paraplegic. The patient is about to be discharged from the rehabilitation centre. Prevention of pressure injury has been an important part of the patient's education. In providing this education, the nurse should have included which of the following guidelines? - ANS: The patient should shift the weight in a chair every 15 minutes.

During the skin assessment of an older patient who had a stroke, the nurse noted a reddened area over the coccyx. The nurse's next action for this patient should include which of the following? - ANS: Repositioning the patient off the coccygeal area and reassessing the area in 1 hour. Which of the following applies to an infected wound? - ANS: It will cause increased drainage, pain, and periwound erythema. Which of the following is typical of venous stasis ulcers? - ANS: They are shallow, irregularly shaped wounds on the lower legs. Diabetic ulcers, occurring most commonly over bony prominences located on the plantar surface of the foot, over the metatarsal heads, and beneath the heels, result from which of the following? - ANS: Neuropathic changes.