skin

Question 1

The nurse is working on a medical-surgical unit that has been participating in a research
project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a
patient to pressure ulcer development include

Answer 1

Alteration in level of consciousness.

Question 2

The nurse is caring for a patient who was involved in an automobile accident 2 weeks
ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the
major element involved in the development of a decubitus ulcer is

Answer 2

Pressure.

Question 3

Which nursing observation would indicate that the patient was at risk for pressure ulcer
formation?

Answer 3

The patient has fecal incontinence.

Question 4

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring
a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is
observed. How would the nurse stage this ulcer?

Answer 4

Healing stage III pressure ulcer

Question 5

The nurse is admitting an older patient from a nursing home. During the assessment, the
nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer
would be staged as stage

Answer 5

II

Question 6

The nurse is completing a skin assessment on a patient with darkly pigmented skin.
Which of the following would be used first to assist in staging an ulcer on this patient?

Answer 6

Halogen light

Question 7

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a
pressure ulcer takes time to heal and is an example of

Answer 7

Full-thickness wound repair.

Question 8

The nurse is caring for a patient with a large abrasion from a motorcycle accident. The
nurse recalls that if the wound is kept moist, it can resurface in _____ day(s).

Answer 8

4

Question 9

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse
would expect to see which of the following in this type of repair?

Answer 9

Granulation

Question 10

The nurse is caring for a patient who has experienced a laparoscopic appendectomy.
The nurse recalls that this type of wound heals by

Answer 10

Primary intention

Question 11

The nurse is caring for a patient in the burn unit. The nurse recalls that this type of
wound heals by

Answer 11

secondary intention

Question 12

Which nursing observation would indicate that a wound healed by secondary
intention?

Answer 12

Scarring can be severe.

Question 13

The nurse is caring for a patient who has experienced a total hysterectomy. Which
nursing observation would indicate that the patient was experiencing a complication of wound
healing?

Answer 13

The incision has a mass, bluish in color.

Question 14

Which of these findings if seen in a postoperative patient should the nurse associate
with dehiscence?

Answer 14

Complaint by patient that something has given way

Question 15

A patient has developed a decubitus ulcer. What laboratory data would be important to
gather?

Answer 15

Serum albumin

Question 16

Which of the following would be the most important piece of assessment data to gather
with regard to wound healing?

Answer 16

Pulse oximetry assessment

Question 17

The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering
the room, the nurse notices an odor and observes a purulent discharge, along with increased redness
at the wound site. What is the next best step for the nurse?

Answer 17

Complete the head-to-toe assessment, and include current treatment, vital signs, and
laboratory results.

Question 18

The nurse is collaborating with the dietitian about a patient with a stage III pressure
ulcer. After the collaboration, the nurse orders a meal plan that includes increased

Answer 18

protein

Question 19

The nurse is completing an assessment on an individual who has a stage IV pressure
ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient
is experiencing issues with self-concept when the patient states which of the following?

Answer 19

“I am ready for my bath and linen change as soon as possible.”

Question 20

A patient presents to the emergency department with a laceration of the right forearm
caused by a fall. After determining that the patient is stable, the next best step is to

Answer 20

Inspect the wound for bleeding.

Question 21

The nurse is caring for a patient on the medical-surgical unit with a wound that has a
drain and a dressing that needs changing. Which of these actions should the nurse take first?

Answer 21

Provide analgesic medications as ordered.

Question 22

The nurse is caring for a patient who has a wound drain with a collection device. The
nurse notices that the collection device has a sudden decrease in drainage. What would be the
nurse’s next best step?

Answer 22

Call the physician; a blockage is present in the tubing.

Question 23

The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic
surgery consultation. Which of the following specialty beds would be most appropriate?

Answer 23

Nonpowered redistribution air mattress

Question 24

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black.
The nurse recognizes that the next step in caring for this patient includes

Answer 24

Débridement of the wound.

Question 25

The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question?

Answer 25

Irrigate with hydrogen peroxide.

Question 26

The nurse is completing an assessment of the skin’s integrity, which includes

Answer 26

Pressure points.

Question 27

The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient’s Braden scale total score?

Answer 27

20

Question 28

The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient’s willingness and ability to increase mobility, which intervention is most important for the nurse to complete?

Answer 28

Provide analgesic medication as ordered.

Question 29

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses?

Answer 29

Impaired skin integrity

Question 30

The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign?

Answer 30

Ineffective tissue perfusion

Question 31

The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient?

Answer 31

Encourage thorough handwashing of all individuals caring for the patient.

Question 32

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a

Answer 32

Registered dietitian.

Question 33

The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient?

Answer 33

The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound.

Question 34

The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for

Answer 34

trauma

Question 35

The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care?

Answer 35

Clean dressings and no touch technique

Question 36

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk?

Answer 36

Gentle cleaners and thorough drying of the skin

Question 37

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?

Answer 37

Less than 2 hours

Question 38

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient?

Answer 38

Utilize a transfer sliding board and assistance to slide the patient into the new position.

Question 39

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage

Answer 39

I

Question 40

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient’s anxiety?

Answer 40

Explain the procedure.

Question 41

The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included?

Answer 41

Cleansing in a direction from the least contaminated area

Question 42

The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder?

Answer 42

The binder supports the abdomen.

Question 43

The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement?

Answer 43

Elevate right knee and apply ice.

Question 44

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing?

Answer 44

23

Question 45

The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.)

Answer 45

a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel

Question 46

The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.)

Answer 46

a. Nutrition c. Tissue perfusion d. Infection f. Age

Question 47

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)

Answer 47

a. “Can you easily change your position?” b. “Do you have sensitivity to heat or cold?” c. “How often do you need to use the toilet?” d. “Is movement painful?”

Question 48

The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.)

Answer 48

b. Hyperemia c. Induration d. Blanching e. Temperature of skin

Question 49

The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse’s responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.)

Answer 49

a. Inspecting the skin for abrasions and edema b. Covering exposed wounds c. Assessing condition of current dressings d. Assessing the skin at underlying areas for circulatory impairment

Question 50

The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.)

Answer 50

b. Prevent injury to the skin and tissues. d. Reduce injury to the skin. e. Reduce injury to the underlying tissues. f. Restore skin integrity.