Unit 6: Ch.29 Skin Integrity and Wound Care

Question 1

Brought together

Answer 1

Approximated

Question 2

Abnormal connection between two internal organs or between an internal organ and the outside of the body

Answer 2

Fistula

Question 3

Removal of necrotic tissue

Answer 3

Debridement

Question 4

Usually indicates bleeding and is bright red

Answer 4

Sanguineous

Question 5

Phenomenon that occurs through the relationship between friction and gravity

Answer 5

Shear

Question 6

Partial or complete separation of the tissue layers during the healing process.

Answer 6

Dehiscence

Question 7

Clear, watery fluid from plasma

Answer 7

Serous

Question 8

Drainage is pink to pale red and contains a mix of clear fluid and red, bloody fluid.

Answer 8

Serosanguineous

Question 9

Necrotic tissue

Answer 9

Eschar

Question 10

Total separation of the tissue layers, allowing the protrusion of visceral organs through the incision.

Answer 10

Evisceration

Question 11

How can Vascular Disease affect skin integrity?

Answer 11

Impacts the skin’s ability to obtain required oxygen and nutrients.

Question 12

How does malnutrition affect skin integrity?

Answer 12

Inadequate intake of proteins, cholesterol, fatty acids, vitamins, and minerals leads to weight loss and the decreased ability of the tissue to withstand pressure, shear, and infection.

Question 13

How does aging affect skin integrity?

Answer 13

As people age, it is more likely that they will have some comorbidity (diabetes/ cardiovascular disease), take meds that affect the skin, and exhibit damage to the skin from ultraviolet light exposure over the years.
-Elderly: sagging/wrinkling of the skin and dry, paper-thin appearance.

Question 14

How does spinal injuries affect skin integrity?

Answer 14

Patients with disabilities that cause difficulty with mobility or sensory perception are at risk for developing pressure injuries. The patient is unable to feel pain (the warning sign of tissue ischemia), respond appropriately, and/or move or maintain position independently.

Question 15

What are some examples of an open wound?

Answer 15

Abrasions, puncture wounds, and surgical incisions.

Question 16

What type of wound heals by primary infection?

Answer 16

Surgical incisions or traumatic wounds.

Question 17

How can the nurse prevent dehiscence and evisceration of a wound?

Answer 17

By teaching the patient to “splint” the incision with a pillow or folded blanket or to use an abdominal binder for comfort while coughing, deep breathing, and during movements.

Question 18

Fistulas can result in?

Answer 18

Fluid and electrolyte loss, nutritional deficits, and alterations in skin integrity.

Question 19

Full-thickness pressure injuries are at which stages?

Answer 19

Stages III, IV, and unstageable.

Question 20

Patients experiencing full-thickness wounds may have permanent loss of their hair follicles, sweat glands, and skin color. True or False.

Answer 20

True

Question 21

What would the nurse observe if maceration was present at a wound?

Answer 21

The wound would appear pale and soft, or the skin will be wrinkled.

Question 22

What would the nurse observe if an infection was present in a wound?

Answer 22

Redness, warmth, and induration are seen with an infection, along with purulent drainage that may appear yellow, greenish, or beige.

Question 23

What does the wound classification RYB indicate?

Answer 23

R- Wound should be beefy red and shiny in appearance.
Y- Yellow is a type of slough tissue.
B- Black is necrotic tissue. The wound will need debridement if yellow and/or black tissue are present.

Question 24

The nurse determines that the patient’s wound may be infected. To perform an aerobic wound culture, the rn should:
a. swab the necrotic tissue area.
b. collect the culture before cleansing the wound.
c. obtain a culturette tube and use sterile technique.
d. place the used swab in a plastic bag and send it to lab.

Answer 24

c. obtain a culturette tube and use sterile technique.

Question 25

Pressure injuries form primarily as a result of which of the following? a. nitrogen buildup in the underlying tissues. b. prolonged illness or disease. c. tissue ischemia d. poor hygiene

Answer 25

c. tissue ischemia

Question 26

The nurse notes that the patient's skin is reddened with a pink wound bed and serous fluid present. The nurse should classify this stage of injury as which of the following? a. Stage I b. Stage II c. Stage III d. Stage IV

Answer 26

b. Stage II

Question 27

The patient has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the patient's skin integrity? a. Have the patient sit up in a chair for 4-hour intervals. b. Keep the head of the bed in a high Fowler position. c. Keep a written schedule of turning and positioning. d. Encourage the patient to perform pelvic muscle training exercises several times daily.

Answer 27

c. Keep a written schedule of turning and positioning.

Question 28

On changing the patient's dressing, the nurse notes that the wound appears to be granulating. An appropriate cleansing agent selected by the rn is? a. sterile saline b. hydrogen peroxide c. povidone-iodine (Betadine) d. sodium hypochlorite (Dakin solution)

Answer 28

a. sterile saline

Question 29

A patient requires wound debridement. The nurse is aware that which one of the following statements is correct regarding procedure? a. It allows the healthy tissue to regenerate. b. When performed by autolytic means, the wound is irrigated. c. Occlusive dressings provide the fastest debridement. d. Mechanical methods involve direct surgical removal of the eschar layer of the wound.

Answer 29

a. It allows the healthy tissue to regenerate.

Question 30

The nurse prepares to irrigate the patient's wound. What is the primary reason for this procedure? a. Create scar formation. b. Remove debris from the wound. c. Improve circulation from the wound. d. Decrease irritation from wound drainage.

Answer 30

b. Remove debris from the wound.

Question 31

When turning a patient, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? a. Soak the area with a normal saline solution. b. Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area. c. Wash the area with an astringent and paint it with povidone-iodine (Betadine). d. Clean the area with mild soap, dry, and add a protective moisturizer.

Answer 31

d. Clean the area with mild soap, dry, and add a protective moisturizer.

Question 32

On inspection of the patient's wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select on the basis of the wound assessment is a. Foam b. Hydrogel c. Hydrocolloid d. transparent film

Answer 32

a. Foam

Question 33

A patient has a healing abdominal wound. The wound has granulation tissue and collagen formation. The nurse identifies the wound as being in which phase of healing? a. Primary intention b. Inflammatory phase c. Proliferative phase d. Secondary intention

Answer 33

c. Proliferative phase

Question 34

The nurse is concerned that the patient's midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication? a. Administering antibiotics to prevent infection. b. Using appropriate sterile technique when changing the dressing. c. Keeping sterile towels and extra dressing supplies near the patient's bed. d. Having the patient splint the incision site when coughing.

Answer 34

d. Having the patient splint the incision site when coughing.

Question 35

After an injury, the patient has thick, yellow drainage coming from the wound. The nurse describes this drainage as a. milky b. serous c. purulent d. serosanguineous

Answer 35

c. purulent

Question 36

Which nursing entry is most complete in describing a patient's wound? a. Incision edges approximated without redness or drainage, two 4 x 4s applied. b. Wound appears to be healing well. Dressing dry and intact. c. Wound coming together with minimal drainage. d. Small amount of drainage size of quarter, dressing applied.

Answer 36

a. Incision edges approximated without redness or drainage, two 4 x 4s applied.

Question 37

The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the patient who has been exposed to a. urine b. purulent exudates c. pancreatic fluids d. serosanguineous drainage

Answer 37

c. pancreatic fluids

Question 38

When cleaning a wound, the nurse should do which of the following first? a. Go over the wound twice and discard that swab. b. Move from the outer region of the wound toward the center. c. Start at the drainage site and move outward with circular motions. d. Use an enzyme solution followed by a saline rinse.

Answer 38

c. Start at the drainage site and move outward with circular motions.

Question 39

The patient has a large, deep wound on the sacral region. The rn correctly packs the wound by a. filling half of the wound cavity. b. using dripping-wet gauze. c. putting the dressing in tightly. d. extending only to the upper edge of the wound.

Answer 39

d. extending only to the upper edge of the wound.

Question 40

The nurse is aware that application of cold is indicated for the patient with which of the following? a. A fractured ankle b. Menstrual cramps c. An infected wound d. Degenerative joint disease

Answer 40

a. A fractured ankle

Question 41

The nurse uses the Norton Scale in the extended care facility to determine the patient's risk for pressure injury development. Which of the following scores, based on this scale, places the patient at the highest level of risk? a. 6 b. 8 c. 15 d. 19

Answer 41

a. 6

Question 42

The patient requires bandaging to the LE. The nurse correctly implements the use of a bandage by: a. using it as a replacement for underlying dressings. b. making sure the patient has a distal pulse. c. keeping it loose for patient comfort. d. having the patient sit or stand when it is applied.

Answer 42

b. making sure the patient has a distal pulse.

Question 43

The patient is brought into the ED with a knife wound. The nurse correctly documents the patient's wound as a(n) a. acute wound b. clean wound c. chronic wound d. contusion wound

Answer 43

a. acute wound

Question 44

The nurse is planning a program on wound healing and includes information that smoking influences healing by a. suppressing protein synthesis. b. creating increased tissue fragility. c. depressing systematic bone marrow function. d. reducing hemoglobin's ability to carry oxygen.

Answer 44

d. reducing hemoglobin's ability to carry oxygen.

Question 45

A patient on the medical unit is taking steroids and also has a wound from a minor injury. To promote wound healing for this patient, the nurse recommends that which of the following be specifically added? a. Iron b. Folic acid c. Vitamin C d. B-complex vitamins

Answer 45

c. Vitamin C

Question 46

A wound that results from surgery where the organ systems are likely to contain bacteria is also known as a(n) a. clean wound. b. infected wound. c. contaminated wound. d. clean-contaminated wound

Answer 46

d. clean-contaminated wound

Question 47

What happens during the inflammatory stage of wound healing? a. Collagen formation. b. Scar tissue development. c. Coagulation cascade. d. Wound contraction.

Answer 47

c. Coagulation cascade.

Question 48

Granulation tissue is assessed by the nurse as appearing a. "beefy" red and moist. b. pale grey and dry. c. dark black and hard. d. light pink and dry.

Answer 48

a. "beefy" red and moist.

Question 49

The patient is to have a dressing change with wound care. Last time, the patient was uncomfortable during the procedure. What should the nurse do to reduce discomfort for this care? a. Premedicate the patient 30 minutes before the procedure. b. Swab the wound with a local anesthetic. c. Perform the wound care quickly. d. Continue with the procedure.

Answer 49

a. Premedicate the patient 30 minutes before the procedure.

Question 50

The unit manager is observing the new staff nurse perform a wet/damp-to-dry dressing change. Which of the following actions requires correction by the manager? a. Providing information on the procedure to the patient. b. Applying clean, nonsterile gloves to remove the old dressing. c. Holding the skin taut to remove the old dressing. d. Moistening the dressing to facilitate removal.

Answer 50

d. Moistening the dressing to facilitate removal.

Question 51

Of these steps in the procedure, which of the following is done first in the wet/damp-to-dry dressing application? a. Preparing the packing gauze. b. Irrigating the wound. c. Moistening the packing. d. Cleaning the wound with sterile saline.

Answer 51

b. Irrigating the wound.