Question 1

A patient is wearing an abdominal binder after abdominal surgery.What does the nurse need to assess and document about the patient?

Accepted Answer

Evaluate the patient's ability to ventilate properly,including deep breathing and coughing.An abdominal binder supports a large incision that is vulnerable to stress when a patient moves or coughs.Neurological,lymphatic,and genitourinary responses are not affected by the abdominal binder.

Question 2

A patient who has undergone a colectomy is demonstrating wound healing.The nurse correctly identifies the wound phase characterized by synthesis of collagen fibers as which of the following?

Accepted Answer

The proliferative phase,in wound healing by primary intention,causes new capillary networks to form that provide oxygen and nutrients for new tissue and contribute to the synthesis of collagen.In the inflammation phase the goal is to establish a clean wound bed and obtain bacterial balance.If exudate brings white blood cells to the area,a scab will form.When wounds involve loss of tissue,such as a severe laceration or chronic wound,these heal by secondary intention.Hemostasis phase controls bleeding.

Question 3

A patient is being seen in the Emergency Department for a puncture wound on the foot.The patient was walking in a construction site,but is unsure what caused the injury.During the initial assessment the nurse determines if the patient has received a tetanus toxoid injection within which time frame?

Accepted Answer

When an injury results from trauma from a dirty penetrating object,determine if the patient has received a tetanus toxoid injection within the last 10 years.Within the past year,3 years,or 5 years is too early.

Question 4

Which therapy should the nurse choose that will improve a patient's circulation,relieve edema,and promote concentration of pus and drainage?

Accepted Answer

A warm moist compress improves circulation,relieves edema,and promotes concentration of pus and drainage.Warm soaks involve the immersion of a body part in a warmed solution that promotes circulation,lessens edema,increases muscle relaxation,and allows application of medicated solution.The patient who has had rectal surgery or an episiotomy during childbirth or who has painful hemorrhoids or vaginal inflammation will benefit from a sitz bath,a bath in which only the pelvic area is immersed in warm fluid.Cold moist compresses are used to relieve inflammation and swelling.

Question 5

An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework.During a bath,the assistive nursing personnel noticed that there was a large blister on the patient's right heel.The patient denies knowledge of having injured self.It was reported to the nurse who correctly documented it as what stage of a pressure ulcer?

Accepted Answer

Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage I: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling

Question 6

Assistive personnel ask the nurse the differences between wound healing by primary and secondary intention.The nurse's best response is that healing by primary intention occurs when the skin edges:

Accepted Answer

A wound with little or no tissue loss,such as a clean surgical incision,heals by primary intention.The skin edges approximate,or close together (not overlapping),and the risk for infection is minimal.In contrast,a wound involving loss of tissue such as a severe laceration or a chronic wound such as a pressure ulcer heals by secondary intention.The skin edges cannot come together because of the extensive tissue loss,and healing occurs gradually.A layer of granulation tissue,which is red,moist tissue consisting of blood vessels and connective tissue,covers the wound base in secondary intention.

Question 7

The student nurse asks a nursing assistive personnel (NAP)to help move a patient up in bed.The student nurse instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation?

Accepted Answer

Shear is the force exerted against the skin while the skin remains stationary and the bony structures move.For example,when the head of the bed is elevated,gravity causes the bony skeleton to pull toward the foot of the bed,while the skin remains against the sheets.Friction is surface damage caused by the skin rubbing against another surface that often results in an abrasion.Friction would result if the patient is dragged across the sheets.Skin moisture increases the risk for ulcer formation as moisture softens the skin and reduces its resistance to other physical factors such as pressure or shear.Moisture comes from many sources such as wound drainage,perspiration,and/or fecal and urinary incontinence.With continuous pressure over the area,deep tissue destruction continues,which often results in larger pockets of necrotic tissue beneath the opening of the main wound that resemble a tunnel; this is referred to as tunneling.

Question 8

A patient's draining wound is pale and watery with a combination of plasma and red cells.How should the nurse document this finding?

Accepted Answer

Serosanguineous is pale,more watery,and a combination of plasma and red cells,which may be blood streaked.Serous is clear,watery plasma.Purulent is thick,yellow,green,or brown,indicating the presence of dead or living organisms and white blood cells.Sanguineous is fresh bleeding.

Question 9

The primary health care provider has ordered the patient to wear an elastic bandage to the left ankle owing to a severe strain.The nurse has instructed the patient on proper application of the elastic bandage.Which statement indicates the patient needs more teaching?

Accepted Answer

The response: "I need to wrap the bandage toward my toes" is the correct answer because the patient is wrapping the bandage from the proximal boundary to the distal boundary.Proper application of the bandage is from distal point toward proximal boundary,stretching the dressing slightly,using a variety of bandage turns to cover various body shapes.Prevent uneven dressing tension or circulatory impairment by overlapping turns by one-half to two-thirds width of dressing roll.Be sure the bandage is smooth (without creases).Evaluate circulation to dressing area every 4 hours by palpating distal pulse,palpating skin,noting temperature and observing skin color.Saying,"make sure the bandage is smooth," "watch my toes for swelling and feeling cold," and "call the physician if I experience increased pain" are all correct and require no teaching.

Question 10

The nurse is preparing to change a large wound dressing on the patient's buttock.Which intervention should the nurse address first?

Accepted Answer

When you plan a dressing change,consider giving the patient an analgesic at least 30 minutes before exposing a wound.Then assess the appearance of the wound.Next,assess the character of wound drainage by noting the amount,color,odor,and consistency.Then assess the drains.Drains lie within tissue,extend from the skin,and are connected to a drainage bag or suction apparatus or allowed to drain into a dressing.Most drains attach to a collection device.First,observe the security of the drain and its location with respect to the wound.Next,note the character and amount of drainage if there is a collecting device.In the case of a surgical wound,inspect the staples,sutures,or wound closures for irritation,and note whether the wound edges are intact.

Question 11

An elderly patient is admitted to the hospital for a bowel obstruction.The patient is immobile and the nurse notices that there is a reddened area on the right heel.When the nurse presses on the area it does not turn lighter in color.How should the nurse document the tissue condition?

Accepted Answer

Nonblanchable hyperemia is redness that persists after palpation and indicates tissue damage.When you press a finger against the red or purple area,it does not turn lighter in color.Deep tissue damage is present and is commonly the first stage of pressure ulcer development.Reactive hyperemia is a redness of the skin resulting from dilation of the superficial capillaries.Reactive hyperemia blanches.In blanchable hyperemia,the area that appears red and warm will blanch (turn lighter in color)following fingertip palpation.Tissue ischemia,decreased blood flow to tissue,usually results in tissue death and occurs when capillary blood flow is obstructed,as in the case of pressure.

Question 12

An elderly patient who resides in a nursing home is suffering from a respiratory infection.During the illness,the patient has become incontinent of both urine and stool.The nursing staff used a special cleanser on the perineum,put a moisture barrier on the exposed area,and used absorbent briefs to prevent the skin from becoming soft because of the moisture.What was the staff trying to prevent?

Accepted Answer

The staff is preventing maceration.For a patient who is incontinent of stool or urine,use a specialized incontinence cleanser.To protect the skin you apply a moisture barrier product (generally petrolatum or dimethicone based)liberally to the exposed area.Select underpads,diapers,or briefs that are absorbent to wick incontinence moisture away from the skin versus trapping the moisture against the skin,which causes maceration (softening of the skin because of moisture).To maintain a stable environment it is important to control infection and promote cleansing,debride (remove)necrotic tissue,provide exudate management,control dead space,and provide wound protection.Dehiscence is the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly.Evisceration occurs when wound layers separate below the fascial layer,and visceral organs protrude through the wound opening.

Question 13

A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus.The admitting nurse notes that an area of redness on the right malleolus is nonblanchable.The nurse correctly identifies this pressure ulcer at what stage?

Accepted Answer

Stage I: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling

Question 14

A patient is admitted to the hospital with a pressure ulcer on the sacrum.The wound is open with exposed bone.The nurse should document this pressure ulcer at what stage?

Accepted Answer

Stage IV: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling
Stage I: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling

Question 15

A postoperative patient visits the ambulatory care clinic complaining of just "not feeling well." The patient has an elevated temperature.Which assessment finding should indicate to the nurse that the wound has become infected?

Accepted Answer

Purulent drainage indicates an infection as it contains dead or living organisms and white blood cells and is often yellow,green,or brown.If the drainage has a pungent or strong odor,an infection is likely.No odor indicates normal healing.When an infection develops,the wound edges are usually brightly inflamed,warm,tender,and swollen.Culture results would come back positive for bacteria if an infection is present; a negative culture indicates no infection is present.

Question 16

A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan.The admitting diagnosis is failure-to-thrive.On admission,the patient was found to have a wound on the right scapula.The nurse noted full-thickness tissue loss with tunneling,but did not note any bone,tendon,or muscle.This was correctly identified as what stage of a pressure ulcer?

Accepted Answer

Stage III: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage I: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage IV: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling

Question 17

A surgical wound requires a hydrogel dressing.What is the primary advantage of a hydrogel dressing?

Accepted Answer

Hydrogels maintain moisture in some wounds for 1 to 3 days.Hydrogel dressings are available in sheets or in a gel in a tube (amorphous).They contain a high percentage of water and are indicated for wounds that require moisture,either a wound with granulation (maintaining the moist wound environment needed for healing)or a wound that has a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue).Negative pressure wound therapy (NPWT)uses negative pressure to assist wound healing.Negative pressure wound therapy supports wound healing by evacuating wound fluids,stimulating granulation tissue formation,reducing the bacterial burden of a wound,and maintaining a moist wound environment.Gauze dressings are best for wounds with moderate drainage,deep wounds,undermining,and tunnels.You apply gauze either moist or dry.The moistened gauze increases the absorptive ability of the dressing to collect exudate.A transparent or hydrocolloid dressing protects against the external environment.

Question 18

The nurse is caring for a patient with a necrotic hip wound.Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?

Accepted Answer

Hydrogel dressings are available in sheets or in a gel in a tube (amorphous).They contain a high percentage of water and are indicated for wounds that require moisture,either a wound with granulation (maintaining the moist wound environment needed for healing)or a wound that has a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue).Gauze dressings are best for wounds with moderate drainage,deep wounds,undermining,and tunnels.Transparent film dressings are used as a primary dressing in wounds with minimal tissue loss that have very little wound drainage.Hydrocolloid dressings are used for stage I,II,and III pressure ulcers.

Question 19

Which patient is best suited for heat therapy?

Accepted Answer

Low back pain treatment of heat is used to promote muscle relaxation,and reduces pain from spasm or stiffness.Do not apply heat over an active area of bleeding (risk for continued bleeding)or an acute localized inflammation such as appendicitis (risk for rupture).Cold therapy,not heat,is indicated for a first-degree burn.

Question 20

An elderly patient has been admitted to the hospital for pneumonia.Which factor could put this patient at risk for a pressure ulcer?

Accepted Answer

Poor nutrition,specifically severe protein deficiency,causes soft tissue to become susceptible to breakdown.Low protein levels cause edema or swelling,which contributes to problems with the transportation of oxygen and nutrients.A hospitalized adult with a score of 16 or below and an older adult at 18 or below are at risk for pressure ulcer development; a score of 22 does not place the patient at risk.A patient with decreased mobility,inadequate nutrition,excessive skin moisture,decreased sensory perception,or decreased activity is at risk for pressure ulcer development.Repositioning a patient every 2 hours will help prevent pressure ulcers.Activity as tolerated will help prevent pressure ulcers.

Quiz 37: Skin Integrity and Wound Care