Download Skin Integrity Sample questions.docx and more Exams Nursing in PDF only on Docsity!
Skin Integrity Sample questions
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? A. An individual's skin changes little over the life span. B. In children younger than 2 years, the skin is thicker and stronger than in adults. C. An infant's skin and mucous membranes are easily injured and at risk for infection. D. A child's skin becomes less resistant to injury and infection as the child grows. - correct answer c. An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows. A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True False - correct answer True A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage. The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? A. Banana B. Fish C. Green beans D. Pasta salad - correct answer B
To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish. The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter? A. transparent film B. hydrogel sheet C. hydrocolloid dressing D. 2 × 2 in (5 × 5 cm) gauze - correct answer A To secure an IV catheter, the nurse uses a transparent film. The transparency film allows visualization of the IV site, is self-adhesive, and protects against contamination. The 2 × 2 in (5 × 5 cm) gauze dressing does not allow visualization of the IV site and does not protect against moisture. The hydrocolloid dressing does not allow visualization of the IV site and is best used in wounds with light to moderate drainage. Hydrogel sheets are not an appropriate dressing for an IV site. They do not allow visualization of the IV site and are best used in partial- and full- thickness wounds, burns, dry wounds, wounds with minimal exudate, necrotic wounds, and infected wounds. A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? A. Tetanus, being able to walk, and scarring B. Scarring, sutures, and wound care C. Tetanus, infection, wound care, and pain control D. Prevention of recurring infection, ability to work, and wound care - correct answer C. Chances are the client knows that stepping on a nail could lead to a serious complication or illness, even if the client cannot remember or does not know about
D. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. F. Serosanguineous drainage can be dark yellow or green depending on the causative organism. - correct answer a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged. A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. A. Notify the health care provider of the situation. B. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. C. Place the patient in the low Fowler's position. - correct answer c, b, a. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position (to prevent further physical damage), cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). Note that the interprofessional team may be completing the activities simultaneously in the clinical setting, but the priority identified above is important to understand. A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? A. Pain B. Impaired Skin Integrity
C. Disturbed D. Body Image Disturbed Thought Processes - correct answer D A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? A. Using sterile dressing supplies B. Suggesting dietary supplements C. Applying antibiotic ointment D. Performing careful hand hygiene - correct answer d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important. A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. A. Hemostasis occurs immediately after the initial injury. B. A liquid called exudate is formed during the proliferation phase. C. White blood cells move to the wound in the inflammatory phase. D. Granulation tissue forms in the inflammatory phase. E. During the inflammatory phase, the patient has generalized body response. A scar forms during the proliferation phase. - correct answer a, c, e
. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar. The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. A. Enhanced healing due to the presence of sugars and proteins
A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. A. The patient takes time to think about responses to questions. B. The patient is 86 years old. C. The patient reports inability to control urine. D. The patient is scheduled for a hip arthroplasty. E. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). F. The patient reports increased pain in right hip when repositioning in bed or chair - correct answer b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure injury development. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development. A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? A. "I can expect to have more discomfort in the area where the cold is applied." B. "I should expect more drainage from the incision after the ice has been in place." C. "I should see less swelling and redness with the cold treatment." D. "My incision may bleed more when the ice is first applied." - correct answer c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation
of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding. A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? A. The therapy is used to collect excess blood loss and prevent the formation of a scab. B. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. C. The therapy provides a moist environment and stimulates blood flow to the wound. D. The therapy irrigates the wound to keep it free from debris and excess wound fluid - correct answer c. Negative pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly. After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 - correct answer b. A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound?
D. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker. - correct answer a. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.
