Flashcards in Exam 4 (Ch 34 Test Questions) Deck (36):
1. What is the function of the stratum corneum?
1) Provides insulation for temperature regulation
2) Provides strength and elasticity to the skin
3) Protects the body against the entry of pathogens
4) Continually produces new skin cells
2. Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives:
1) Can cause cellular toxicity.
2) Increase the risk of ischemia.
3) Delay wound healing.
4) Predispose to hematoma formation.
3. What is the primary difference between acute and chronic wounds? Chronic wounds:
1) Are full-thickness wounds, but acute wounds are superficial.
2) Result from pressure, but acute wounds result from surgery.
3) Are usually infected, whereas acute wounds are contaminated.
4) Exceed the typical healing time, but acute wounds heal readily.
4. A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?
1) Partial-thickness wound
2) Penetrating wound
3) Superficial wound
4) Full-thickness wound
5. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:
1) Primary intention healing.
2) Secondary intention healing.
3) Tertiary intention healing.
4) Approximation healing.
6. When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make?
1) The patient will need to take antibiotics until the wound is completely healed.
2) Because the patient’s wound was left open, the wound will likely become infected.
3) The patient will have more scar tissue formation than for a wound closed at surgery.
4) The patient should expect to remain hospitalized until complete wound healing occurs.
7. What is the primary goal that the nurse should establish for a patient with an open wound?
1) The wound will remain free of infection throughout the healing process.
2) Client completes antibiotic treatment as ordered.
3) The wound will remain free of scar tissue at healing.
4) Client increases caloric intake throughout the healing process.
8. While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as?
9. Three days ago a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication?
1) Deep vein thrombosis
2) Dehiscence of the wound
3) Internal bleeding
4) Infection at the incisional site
10. Which of the following describes the difference between dehiscence and evisceration?
1) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.
2) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent.
3) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue.
4) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.
11. The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client
1) begins an aggressive exercise program.
2) follows a diet plan of 1,000 calories per day.
3) is fitted for deep-depth diabetic footwear.
4) remains free of foot wounds.
12. Pressure ulcers are directly caused by which of the following conditions at the site?
1) Compromised blood flow
3) Shearing forces
4) Inadequate venous return
13. A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?
1) Stage II pressure ulcer
2) Stage III pressure ulcer
3) Stage IV pressure ulcer
4) Unstageable pressure ulcer
14. A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?
1) Stage I pressure ulcer, healing
2) Stage II pressure ulcer, healing
3) Stage III pressure ulcer, healing
4) Stage IV pressure ulcer, healing
15. A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?
1) Draw a circle around the area of drainage on a dressing.
2) Classify drainage as less or more than the previous drainage.
3) Weigh the patient at the same time each day on the same scale.
4) Weigh dressings before they are applied and after they are removed.
16. A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patient’s left heel. What is the initial treatment for this pressure ulcer?
1) Antibiotic treatment for 2 weeks
2) Normal saline irrigation of the ulcer daily
3) Débridement to the left heel
4) Elevation of the left heel off the bed
17. Why is the information obtained from a swab culture of a wound limited?
1) A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria.
2) A negative culture may not indicate infection because chronic wounds are often colonized with bacteria.
3) Most wound infections are viral, so the swab culture would not be indicative of a wound infection.
4) A swab culture result does not include bacterial sensitivity information necessary to provide treatment.
18. For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be?
1) Client will maintain intact skin throughout hospitalization.
2) Client will limit pressure to wound site throughout treatment course.
3) Wound will close with no evidence of infection within 6 weeks.
4) Wound will improve prior to discharge as evidenced by a decrease in drainage.
19. A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time?
1) Risk for Infection related to subcutaneous injuries
2) Risk for Impaired Skin Integrity related to immobility
3) Impaired Tissue Integrity related to ventilator dependency
4) Impaired Skin Integrity related to ventilator dependency
20. What intervention would be most appropriate for a wound with a beefy red wound bed?
1) Mechanical débridement
2) Autolytic debridement
3) Dressing to keep the wound moist and clean
4) Removal of devitalized tissue and a sterile dressing
21. A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound?
1) Dry gauze dressing changed twice daily
2) Nonadherent dressing with daily wound care
3) Hydrocolloid dressing changed as needed
4) Wet-to-dry dressings changed 3 times a day
22. The nurse would know care for a stage II pressure ulcer is achieving the desired goal when:
1) The ulcer is completely healed with minimal scarring.
2) The patient reports no pain at the site.
3) A minimal amount of drainage is noted.
4) The wound bed contains 100% granulated tissue.
23. Your patient has a deep wound on the right hip, with tunneling at the 8 o’clock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice?
1) Alginate dressing
2) Dry gauze dressing
4) Hydrocolloid dressing
24. Of the following, which is the best choice for performing wound irrigation?
1) Water jet irrigation
2) 35-cc syringe with a 19-gauge angiocatheter
3) 5-cc syringe with a 23-gauge needle
4) Bulb syringe
25. Your patient has multiple open wounds that require treatment. When performing dressing changes, you should:
1) Remove all of the soiled dressings before beginning wound treatment.
2) Cleanse wounds from most contaminated to least contaminated.
3) Treat wounds on the patient’s side first, then the front and back of the patient.
4) Irrigate wounds from least contaminated to most contaminated.
26. A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following?
2) Abdominal binder
4) Paper tape
27. A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient?
1) Transparent film dressing
2) Sheet hydrogel
3) Frequent turn schedule
4) Enzymatic débridement
28. When applying heat or cold therapy to a wound, what should the nurse do?
1) Leave the therapy on each area no longer than 15 minutes.
2) Leave the therapy on each area no longer than 30 minutes.
3) When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it.
4) When using cold, ensure the temperature is less than 32°F (0°C) before applying it.
29. A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound “heals a little more” he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing?
1) Primary intention
2) Regenerative healing
3) Secondary intention
4) Tertiary intention
30. What is a common characteristic of aging skin?
1) Increased permeability to moisture
2) Diminished sweat gland activity
3) Reduced oxygen-free radicals
4) Overproduction of elastin
31. Which client does the nurse recognize as being at greatest risk for pressure ulcers?
1) Infant with skin excoriations in the diaper region
2) Young adult with diabetes in skeletal traction
3) Middle-aged adult with quadriplegia
4) Older adult requiring use of assistive device for ambulation
32. The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? Choose all that apply.
1) Is actively bleeding
2) Has swollen, tender insect bite
3) Has just sprained her ankle
4) Has lower back pain
1. Select the process(es) that occur(s) during the inflammatory phase of wound healing. Choose all that apply.
2. What are two risk assessment tools used in the United States to evaluate a patient’s risk for skin problems? Choose all that apply.
1) FLACC scale
2) Waterlow scale
3) Braden scale
4) Norton scale
3. Which of the following are examples of nonselective mechanical débridement methods? Choose all that apply.
1) Wet-to-dry dressings
2) Sharp débridement
4) Pulsed lavage