Question 1

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?

Accepted Answer

If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the surgeon immediately. Putting pressure on the wound could cause further complications. Transparent films are used for autolytic debridement. A gauze pad will allow the wound to become dry and cause further complications.

Question 2

The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse should place the head of the bed in which position?

Accepted Answer

When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.

Question 3

The nurse identifies which syringe to use when irrigating a patient's deep wound?

Accepted Answer

A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi.

Question 4

The nurse understands which rationale to be appropriate for drying a wound after irrigation?

Accepted Answer

Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being removed and reduces trauma to the wound. The type of dressing will determine how it lays in the wound and whether it is occlusive. The drying does not prevent infection.

Question 5

A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?

Accepted Answer

Assessment and evaluation of a patient's skin and wounds, and the effectiveness of the treatment plan, are a nurse's responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.

Question 6

The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding?

Accepted Answer

Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and are contraindicated in infected wounds. It is the most comfortable form of debridement for the patient.

Question 7

When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?

Accepted Answer

The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction. Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.

Question 8

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a "popping sensation" and a wetness in the dressing, the nurse immediately suspects which complication?

Accepted Answer

Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

Question 9

The nurse recognizes which intervention is not a form of mechanical debridement?

Accepted Answer

Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

Question 10

The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing?

Accepted Answer

Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin's ability to obtain required oxygen and nutrients, or diabetes, which affects not only the microvasculature, but also the skin's normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal, anti-inflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

Question 11

The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?

Accepted Answer

Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a wound that is tunneling may require packing.

Question 12

The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?

Accepted Answer

The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

Question 13

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first?

Accepted Answer

If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or preexisting. Then the nurse can determine what to do next based on the patient's response.

Question 14

The nurse knows which description would be classified as a closed wound?

Accepted Answer

In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin's surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

Question 15

The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?

Accepted Answer

A stage 3 pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and ambulating twice a day is more of an intervention.

Question 16

When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?

Accepted Answer

Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage 2 pressure ulcers are partial-thickness wounds that involve the epidermis and/or dermis.

Question 17

The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility?

Accepted Answer

Patient will be able to assist with position changes using over bed trapeze within 1 week is an appropriate goal for impaired mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for impaired tissue integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for acute pain. The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Impaired nutritional status.

Question 18

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?

Accepted Answer

An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 10⁵/g of tissue sampled when cultured. The wound will need to be treated for the infection.

Question 19

The nurse identifies which type of wounds heal by tertiary intention?

Accepted Answer

When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.

Question 20

The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for further education?

Accepted Answer

Warm compresses and water for soaks should not be heated in the microwave unless the product and microwave are specifically designed for this type of heating. Ice bags are filled two-thirds full, distilled water is used in Aqua-K pads, and application time for heat is as stated in the PCP order (for cold, it is a maximum of 20 to 30 minutes).

Quiz 29: Skin Integrity and Wound Care