Question 1

The nurse should consider culturing a wound when which one of the following situations occurs?

Accepted Answer

Culturing a wound is necessary when the surrounding area shows inflammation, as this indicates the presence of an infection. A clean and dry wound without exudate or afebrile patient may not necessarily require wound culture.

Question 2

The nurse is caring for a patient who has a dressing over a surgical wound created the night before.The dressing has never been changed.How should the nurse proceed?

Accepted Answer

To promote patient comfort,administer an analgesic as ordered,usually 30 to 45 minutes before changing the dressing.However,you will need to assess to determine the best time for analgesic administration before providing wound care.Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal.The presence of wound exudate is an expected stage of epithelial cell growth.

Question 3

The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx.The patient complains of pain at the site,and the site feels cooler than the areas immediately around the site.The nurse recognizes that this patient has developed

Accepted Answer

A stage 1 pressure injury is characterized by nonblanchable redness of intact skin, often with pain and temperature changes, such as cooler skin compared to surrounding areas.

Question 4

A patient with anemia is at risk for developing pressure injuries as a result of which of the following?

Accepted Answer

Anemia leads to reduced oxygen-carrying capacity of the blood, resulting in diminished oxygen delivery to tissues, which can increase the risk of pressure injuries.

Question 5

The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours.While turning the patient,to what should the nurse who is performing the assessment pay particular attention?

Accepted Answer

Darkly pigmented skin does not always have visible blanching.Its color differs from that of surrounding skin.Skin temperature changes may be an important early indicator of a stage I pressure ulcer.Edema is not an initial indication of a pressure ulcer.Do not massage any reddened or discolored pressure points.Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present.Massage in this area may worsen the inflammation by further damaging underlying damaged blood vessels.Pallor or mottling will be difficult or impossible to see in a patient with darkly pigmented skin.

Question 6

The nurse prepares to irrigate the patient's wound.What is the primary reason for this procedure?

Accepted Answer

The primary reason for wound irrigation is to remove debris from the wound, which can improve healing and prevent infection.

Question 7

Healing by primary intention is expected to occur with which of the following situations?

Accepted Answer

Healing by primary intention occurs when the edges of a clean incision remain close together, which allows for faster healing and minimal scarring. The other options do not describe healing by primary intention.

Question 8

The patient is admitted with an open pressure injury with necrotic tissue around the base of the wound.How would the nurse classify this ulcer?

Accepted Answer

The presence of necrotic tissue makes it impossible to accurately assess the depth of the wound, thus it cannot be staged until the necrotic tissue is removed.

Question 9

A nurse classifies a pressure ulcer according to the type of tissue in the wound bed.What does it indicate if the wound bed has granulation in it?

Accepted Answer

The presence of granulation tissue in the wound bed indicates that the wound is moving toward healing. Granulation tissue is new, healthy tissue that begins to form in the wound bed as part of the healing process. The presence of granulation tissue is a positive sign and suggests that the wound is progressing toward closure.

Question 10

When evaluating a patient,the nurse observes an unexpected outcome of treatment when the surrounding skin of a pressure injury becomes macerated.The nurse should

Accepted Answer

The maceration of surrounding skin indicates excessive moisture, so using dressings with increased moisture absorption can help manage the moisture and prevent further skin breakdown.

Question 11

The nurse is changing a surgical dressing and is cleansing the wound.She knows that

Accepted Answer

The correct technique for cleansing a surgical incision is to start at the center of the incision line and swab toward one end, then use a new swab to clean from the center to the other end. This helps prevent contamination of the wound.

Question 12

In a long-term care facility,how often should the nurse reassess a patient for risk of a pressure ulcer?

Accepted Answer

In a long-term care facility, the patient is assessed every week for 4 weeks and then quarterly, or whenever the patient's condition changes.An assessment schedule of every 1 to 2 days would be more appropriate for acute care than in the long-term care setting.The patient is not reassessed for risk in the long-term setting every time the nurse sees the patient.The new patient in long-term care is reassessed weekly rather than monthly after he is admitted.

Question 13

The patient with a nasogastric (NG)tube in place may experience skin breakdown

Accepted Answer

The NG tube is inserted through the nose, and the skin in the nasal area may become irritated or breakdown due to the constant friction of the tube against the tissue.

Question 14

When teaching about wound care in the home environment,the nurse instructs the patient and caregiver to

Accepted Answer

Normal saline can be made by mixing 8 teaspoons of salt with 3.5 liters of distilled water, which is a common home preparation for wound care.

Question 15

The nurse is caring for four patients during a shift.Which of the following patients is at greatest risk for developing a pressure injury?

Accepted Answer

A Braden Scale score of 8 indicates a very high risk for developing pressure injuries, as the scale ranges from 6 to 23, with lower scores indicating higher risk.

Question 16

On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?

Accepted Answer

Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds.The amount of irrigant is wound size dependent.Pressure settings on the device need to remain between 4 and 15 psi.Do not use this type of irrigation with graft sites or exposed blood vessels,muscle,tendon,or bone.

Question 17

Which of the following approaches is correct technique when wound irrigation is performed?

Accepted Answer

Selecting a soft catheter for deep wounds with small openings is the correct technique for wound irrigation. Placing the patient in a specific position is not necessary for wound irrigation, but the wound should be elevated if possible. Placing the syringe directly into the wound can cause additional damage and is not recommended. Sterile technique should always be used for wound irrigation, regardless of whether the wound is chronic or acute.

Question 18

After teaching a home caregiver how to manage a pressure ulcer,the nurse realizes that further education is needed when the caregiver says:

Accepted Answer

A thick, black covering would not protect the pressure ulcer and could actually make it worse by blocking oxygen flow and harboring bacteria. It is important to keep the wound clean and dry, and to report any changes in drainage or odor to a healthcare provider. Choices A, B, and D are all correct statements about pressure ulcer management.

Question 19

In a patient with a stage 2 pressure injury,the nurse describes the wound as

Accepted Answer

Stage 2 pressure injuries are characterized by partial-thickness skin loss with exposed dermis, often appearing as a superficial blister or shallow open ulcer.

Question 20

The nurse is in the process of irrigating the wound for a patient who has a large pressure injury on his buttock.How should the nurse proceed?

Accepted Answer

The nurse should irrigate the wound so that the solution flows from least contaminated to most contaminated to prevent the spread of microorganisms from the contaminated area to the clean area.

Quiz 39: Prevention and Care of Skin Breakdown