Foundations Chapter 29: Skin Integrity
and Wound Care
1. What does a Braden Score of 14 indicate to the nurse?
a.High risk for the development of pressure ulcers
b.Low risk for the development of pressure ulcers
c.The need for a special mattress
d.The presence of a pressure ulcer - correct answer ANS: A
High risk for the development of pressure ulcers
The lower the score the higher the risk of pressure ulcer formation. While research
continues as to where the cut off for risk should be, it is generally accepted that a
Braden of 16-18 indicates an increased risk for pressure ulcer development. The
Braden score does not indicate which interventions, such as a special mattress, to
use. It does not indicate whether an ulcer already exists.
2. Which is the most appropriate treatment choice for a wound with a shallow pink
wound bed and minimal drainage?
a.Use of an enzymatic debriding agent
b.A moisture retentive dressing such as a hydrocolloid
c.Gauze moistened with 0.9% normal saline
d.An aginate covered with a foam dressing - correct answer ANS: B. A moisture
retentive dressing such as a hydrocolloid
A pink moist wound bed would indicate the presee. Alginate is too absorbent for a
minimally draining wound.nce of granulation tissue. A moist wound environment is
essential for the development of epithelial tissue and so a moisture retentive
dressing is appropriate. Gauze is more labor intensive and does not provide the
moisture retentive environment needed for wound healing. Debridement would
harm healthy granulation tissue
