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Chapter 48: Skin Integrity and Wound Care
Chapter 48: Skin Integrity and Wound Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is working on a medical-surgical unit that has been participating in a research project associated
with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer
development?
a.
Decreased level of consciousness
b.
Adequate dietary intake
c.
Shortness of breath
d.
Muscular pain
ANS: A
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect
themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or
to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear,
friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and an adequate
dietary intake are not included among the predisposing factors.
DIF:Understand (comprehension)REF:1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
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TOP: Assessment MSC: Reduction of Risk Potential
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. Which priority element will the nurse consider when planning care
to decrease the development of a decubitus ulcer?
a.
Resistance
b.
Pressure
c.
Weight
d.
Stress
ANS: B
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to
pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of
the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury
to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin
breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers.
DIF:Understand (comprehension)REF:1185-1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Planning MSC: Reduction of Risk Potential
3. Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
a.
The patient has fecal incontinence.
b.
The patient ate two thirds of breakfast.
c.
The patient has a raised red rash on the right shin.
d.
The patient’s capillary re흿ll is less than 2 seconds.
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ANS: A
The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible
to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary
incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the
skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but
eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg
again is a concern and can a꥿ᖈect the integrity of the skin, but it is located on the shin, which is not a high-risk
area for skin breakdown. Pressure can in㔪uence capillary re흿ll, leading to skin breakdown, but this capillary
response is within normal limits.
DIF:Understand (comprehension)REF:1187
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Assessment MSC: Reduction of Risk Potential
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 should the nurse
document this ulcer in the patient’s medical record?
a.
Stage I pressure ulcer
b.
Healing Stage II pressure ulcer
c.
Healing Stage III pressure ulcer
d.
Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled
with the words “healing stage” or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage
endures even as the ulcer heals. This ulcer was labeled a Stage III, and it cannot return to a previous stage such
as Stage I or II. This ulcer is healing, so it is no longer labeled a Stage III.
DIF:Understand (comprehension)REF:1187
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OBJ: Describe the pressure ulcer staging system. TOP: Implementation
MSC: Physiological Adaptation
5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a
shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this
pressure ulcer?
a.
Stage I
b.
Stage II
c.
Stage III
d.
Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis
and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with
nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be
visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with
exposed bone, tendon, or muscle.
DIF:Apply (application)REF:1187-1188
OBJ: Describe the pressure ulcer staging system. TOP: Assessment
MSC: Physiological Adaptation
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the
nurse use ᯿贄rst to assist in staging an ulcer on this patient?
a.
Disposable measuring tape
b.
Cotton-tipped applicator
c.
Sterile gloves
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d.
Chapter 48: Skin Integrity and Wound Care | Nursing Test Banks
Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the
흿rst step in assessment—inspection—and the entire assessment process. Natural light or a halogen light is
recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere
with an accurate assessment. Other items that could possibly be used during the assessment include gloves for
infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped
applicator to measure the depth of the wound, but these items are not the 흿rst items used.
DIF:Understand (comprehension)REF:1186
OBJ: Describe the pressure ulcer staging system. TOP: Assessment
MSC:Health Promotion and Maintenance
7. The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider
when planning care for this patient?
a.
Partial-thickness wound repair
b.
Full-thickness wound repair
c.
Primary intention
d.
Tertiary intention
ANS: B
Stage IV pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation
because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness
repair has four phases: hemostasis, in㔪ammatory, proliferative, and maturation. A wound heals by primary
intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or
closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are
shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by
regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for
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several days, and then the wound edges are approximated. Wound closure is delayed until risk of infection is
resolved.
DIF:Apply (application)REF:1187 | 1190
OBJ: Discuss the normal process of wound healing. TOP: Planning
MSC: Physiological Adaptation
8. The nurse is caring for a group of patients. Which patient will the nurse see ᯿贄rst?
a.
A patient with a Stage IV pressure ulcer
b.
A patient with a Braden Scale score of 18
c.
A patient with appendicitis using a heating pad
d.
A patient with an incision that is approximated
ANS: C
The nurse should see the patient with an appendicitis 흿rst. Warm applications are contraindicated when the
patient has an acute, localized in㔪ammation such as appendicitis because the heat could cause the appendix to
rupture. Although a Stage IV pressure ulcer is deep, it is not as critical as the appendicitis patient. The total
Braden score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development. A
score of 18 can be assessed later. A healing incision is approximated (closed); this is a normal 흿nding and does
not need to be seen 흿rst.
DIF:Analyze (analysis)REF:1216 | 1218
OBJ:Complete an assessment for a patient with impaired skin integrity.
TOP:AssessmentMSC:Management of Care
9. The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the
nurse expect to observe when the wound is healing?
a.
Eschar
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b.
Slough
c.
Granulation
d.
Purulent drainage
ANS: C
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates
progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to
be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be
removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the
wound to heal.
DIF:Apply (application)REF:1188
OBJ: Discuss the normal process of wound healing. TOP: Assessment
MSC: Physiological Adaptation
10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of
healing will the nurse focus the care plan?
a.
Partial-thickness repair
b.
Secondary intention
c.
Tertiary intention
d.
Primary intention
ANS: D
A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The
skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on
partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis.
These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a
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wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed
until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or
laceration heals by secondary intention. The wound is left open until it becomes 흿lled with scar tissue. It takes
longer for a wound to heal by secondary intention; thus the chance of infection is greater.
DIF:Apply (application)REF:1190
OBJ: Describe the di꥿ᖈerences in wound healing by primary and secondary intention.
TOP: Planning MSC: Physiological Adaptation
11. The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when
planning care for this patient?
a.
Partial-thickness repair
b.
Secondary intention
c.
Tertiary intention
d.
Primary intention
ANS: B
A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention.
The wound is left open until it becomes 흿lled with scar tissue. It takes longer for a wound to heal by secondary
intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little
loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for
infection is low. Partial-thickness repair is done on partial-thickness wounds that are shallow, involving loss of
the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis
regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges
are approximated. Wound closure is delayed until the risk of infection is resolved.
DIF:Understand (comprehension)REF:1190
OBJ: Describe the di꥿ᖈerences in wound healing by primary and secondary intention.
TOP: Planning MSC: Physiological Adaptation
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12. A nurse is assessing a patient’s wound. Which nursing observation will indicate the wound healed by
secondary intention?
a.
Minimal loss of tissue function
b.
Permanent dark redness at site
c.
Minimal scar tissue
d.
Scarring that may be severe
ANS: D
A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left
open until it becomes 흿lled with scar tissue. If the scarring is severe, permanent loss of function often occurs.
Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented
cells and has a lighter color than normal skin.
DIF:Understand (comprehension)REF:1190
OBJ: Describe the di꥿ᖈerences in wound healing by primary and secondary intention.
TOP: Assessment MSC: Physiological Adaptation
13. The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing
observation of the incision will indicate the patient is experiencing a complication of wound healing?
a.
The site is hurting.
b.
The site is approximated.
c.
The site has started to itch.
d.
The site has a mass, bluish in color.
ANS: D
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A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color,
sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or
vein is dangerous because it can put pressure on the vein or artery and obstruct blood 㔪ow. Itching is not a
complication. Incisions should be approximated with edges together; this is a sign of normal healing. After
surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected
that the patient will experience pain.
DIF:Apply (application)REF:1191
OBJ: Describe complications of wound healing. TOP: Assessment
MSC: Reduction of Risk Potential
14. A nurse is caring for a postoperative patient. Which 흿nding will alert the nurse to a potential wound
dehiscence?
a.
Protrusion of visceral organs through a wound opening
b.
Chronic drainage of 㔪uid through the incision site
c.
Report by patient that something has given way
d.
Drainage that is odorous and purulent
ANS: C
Patients often report feeling as though something has given way with dehiscence. Dehiscence occurs when an
incision fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds
and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Evisceration is seen when vital
organs protrude through a wound opening. When there is an increase in serosanguineous drainage from a
wound in the 흿rst few days after surgery, be alert for the potential for dehiscence. Infection is characterized by
drainage that is odorous and purulent.
DIF:Understand (comprehension)REF:1191-1192
OBJ: Describe complications of wound healing. TOP: Assessment
MSC: Reduction of Risk Potential
15. A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?
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a.
Vitamin E
b.
Potassium
c.
Albumin
d.
Sodium
ANS: C
Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition,
and serum albumin is probably the most frequently measured of these parameters. The best measurement of
nutritional status is prealbumin because it re㔪ects not only what the patient has ingested but also what the
body has absorbed, digested, and metabolized. Zinc and copper are the minerals important for wound healing,
not potassium and sodium. Vitamins A and C are important for wound healing, not vitamin E.
DIF:Apply (application)REF:1194-1195
OBJ:Explain the factors that impede or promote wound healing.
TOP: Assessment MSC: Reduction of Risk Potential
16. A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse
to gather with regard to wound healing?
a.
Muscular strength assessment
b.
Pulse oximetry assessment
c.
Sensation assessment
d.
Sleep assessment
ANS: B
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Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate
amounts of oxygenated blood is critical in wound healing. Pulse oximetry measures the oxygen saturation of
blood. Assessment of muscular strength and sensation, although useful for 흿tness and mobility testing, does
not provide any data with regard to wound healing. Sleep, although important for rest and for integration of
learning and restoration of cognitive function, does not provide any data with regard to wound healing.
DIF:Apply (application)REF:1195
OBJ:Explain the factors that impede or promote wound healing.
TOP: Assessment MSC: Reduction of Risk Potential
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?
a.
Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results.
b. Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR).
c.
Consult the wound care nurse about the change in status and the potential for infection.
d. Check with the charge nurse about the change in status and the potential for infection.
ANS: A
The patient is showing signs and symptoms associated with infection in the wound. The nurse should complete
the assessment: gather all data such as current treatment modalities, medications, vital signs including
temperature, and laboratory results such as the most recent complete blood count or white cell count. The
nurse can then notify the primary care provider and receive treatment orders for the patient. It is important to
notify the charge nurse and consult the wound nurse on the patient’s status and on any new orders.
DIF:Apply (application)REF:1191 | 1230
OBJ:Explain the factors that impede or promote wound healing.
TOP: Implementation MSC: Reduction of Risk Potential
18. The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient
will the nurse most likely increase after collaboration with the dietitian?
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a.
Fat
b.
Protein
c.
Vitamin E
d.
Carbohydrate
ANS: B
Protein needs are especially increased in supporting the activity of wound healing. The physiological processes
of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of
zinc and copper. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E will
not be increased for wound healing.
DIF:Apply (application)REF:1194
OBJ:Explain the factors that impede or promote wound healing.
TOP
lanningMSC:Management of Care
19. The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is
odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?
a.
“I am so weak and tired. I want to feel better.”
b.
“I am thinking I will be ready to go home early next week.”
c.
“I am ready for my bath and linen change right now since this is awful.”
d.
“I am hoping there will be something good for dinner tonight.”
ANS: C
Body image changes can in㔪uence self-concept. The wound is odorous, and a drain is in place. The patient who
is asking for a bath and change in linens and states that this is awful gives you a clue that he or she may be
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concerned about the smell in the room. Factors that a꥿ᖈect the patient’s perception of the wound include the
presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The patient’s
stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could
be interpreted as positive statements that indicate progress along the health journey.
DIF:Analyze (analysis)REF:1195
OBJ:Explain the factors that impede or promote wound healing.
TOP: Evaluation MSC: Psychosocial Integrity
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, what is the next best step for the nurse to take?
a.
Inspect the wound for foreign bodies.
b.
Inspect the wound for bleeding.
c.
Determine the size of the wound.
d.
Determine the need for a tetanus antitoxin injection.
ANS: B
After determining that a patient’s condition is stable, inspect the wound for bleeding. An abrasion will have
limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size
and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds
are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose
bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty
penetrating object, determine the need for a tetanus vaccination.
DIF:Apply (application)REF:1198
OBJ: Describe the di꥿ᖈerences between nursing care of acute and chronic wounds.
TOP:ImplementationMSC:Management of Care
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 action should the nurse take ᯿贄rst?
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a.
Provide analgesic medications as ordered.
b.
Avoid accidentally removing the drain.
c.
Don sterile gloves.
d.
Gather supplies.
ANS: A
Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing
a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing
change, donning gloves, and avoiding the accidental removal of the drain during the procedure.
DIF:Apply (application)REF:1198
OBJ: Describe the di꥿ᖈerences between nursing care of acute and chronic wounds.
TOP: Implementation MSC: Physiological Adaptation
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. Which action will the nurse take next?
a.
Call the health care provider; a blockage is present in the tubing.
b.
Chart the results on the intake and output 㔪ow sheet.
c.
Do nothing, as long as the evacuator is compressed.
d.
Remove the drain; a drain is no longer needed.
ANS: A
Because a drainage system needs to be patent, look for drainage 㔪ow through the tubing, as well as around the
tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to
notify the health care provider. The health care provider, not the nurse, determines the need for drain removal
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and removes drains. Charting the results on the intake and output 㔪ow sheet does not take care of the
problem. The evacuator may be compressed even when a blockage is present.
DIF:Apply (application)REF:1199
OBJ: Describe the di꥿ᖈerences between nursing care of acute and chronic wounds.
TOP: Implementation MSC: Reduction of Risk Potential
23. The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which
specialty bed will the nurse use for this patient?
a.
Low-air-loss
b.
Air-㔪uidized
c.
Lateral rotation
d.
Standard mattress
ANS: B
For a patient with newly 㔪apped or grafted surgical sites, the air-㔪uidized bed will be the best choice; this uses
air and 㔪uid support to provide pressure redistribution via a 㔪uid-like medium created by forcing air through
beads as characterized by immersion and envelopment. A low-air-loss bed is utilized for prevention or
treatment of skin breakdown by preventing buildup of moisture and skin breakdown through the use of
air㔪ow. A standard mattress is utilized for an individual who does not have actual or potential altered or
impaired skin integrity. Lateral rotation is used for treatment and prevention of pulmonary, venous stasis and
urinary complications associated with mobility.
DIF:Understand (comprehension)REF:1206
OBJ: Describe the di꥿ᖈerences between nursing care of acute and chronic wounds.
TOP: Planning MSC: Reduction of Risk Potential
24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will
the nurse anticipate?
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a.
Monitor the wound.
b.
Document the wound.
c.
Debride the wound.
d.
Manage drainage from wound.
ANS: C
Debridement is the removal of nonviable necrotic (black) tissue. Removal of necrotic tissue is necessary to rid
the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for
healing. A wound will not move through the phases of healing if the wound is infected. Documentation occurs
after completion of skill. When treating a pressure ulcer, it is important to monitor and reassess the wound at
least every 8 hours. Management of drainage will help keep the wound clean, but that is not the next step.
DIF:Apply (application)REF:1206-1207
OBJ: Describe the di꥿ᖈerences between nursing care of acute and chronic wounds.
TOP: Planning MSC: Physiological Adaptation
25. The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating.
Which health care provider’s order will the nurse question?
a.
Use a low-air-loss therapy unit.
b.
Irrigate with Dakin’s solution.
c.
Apply a hydrogel dressing.
d.
Consult a dietitian.
ANS: B
Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill 흿broblasts and
healing tissue. Cytotoxic cleansers such as Dakin’s solution, acetic acid, povidone-iodine, and hydrogen
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peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a
dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and
applying hydrogel dressings to provide a moist environment for healing are all orders that would be
appropriate.
DIF:Analyze (analysis)REF:1205-1206
OBJ: Describe the di꥿ᖈerences between nursing care of acute and chronic wounds.
TOP:ImplementationMSC:Management of Care
26. The nurse is completing an assessment of the patient’s skin’s integrity. Which assessment is the priority?
a.
Pressure points
b.
Breath sounds
c.
Bowel sounds
d.
Pulse points
ANS: A
Observe pressure points such as bony prominences. The nurse continually assesses the skin for signs of ulcer
development. Assessment for tissue pressure damage includes visual and tactile inspection of the skin.
Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could
in㔪uence the function of the body and ultimately skin integrity; however, this assessment is not a speci흿c part
or priority of a skin assessment.
DIF:Apply (application)REF:1196 | 1221
OBJ:Complete an assessment for a patient with impaired skin integrity.
TOP:AssessmentMSC:Management of Care
27. The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory
impairment, has 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. Which score will the nurse
document for this patient?
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a.
15
b.
17
c.
20
d.
23
ANS: C
With use of the Braden Scale, the total score is a 20. The patient receives 3 for slight sensory perception
impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of
meals, and 4 for no problem with friction and shear.
DIF:Analyze (analysis)REF:1192-1193
OBJ:Complete an assessment for a patient with impaired skin integrity.
TOP:AssessmentMSC:Health Promotion and Maintenance
28. The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to
decrease the risk of pressure ulcers and encourage the patient’s willingness and ability to increase mobility?
a.
Explain the risks of immobility to the patient.
b.
Turn the patient every 3 hours while in bed.
c.
Encourage the patient to sit up in the chair.
d.
Provide analgesic medication as ordered.
ANS: D
Maintaining adequate pain control (providing analgesic medications) and patient comfort increases the
patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. Although sitting
in the chair is bene흿cial, it does not increase mobility or provide pain control. Explaining the risk of immobility
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is important for the patient because it may impact the patient’s willingness but not his or her ability. Turning
the patient is important for decreasing pressure ulcers but needs to be done every 2 hours and, again, does
not in㔪uence the patient’s ability to increase mobility.
DIF:Apply (application)REF:1197-1198
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Reduction of Risk Potential
29. The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add
to the care plan?
a.
Readiness for enhanced nutrition
b.
Impaired physical mobility
c.
Impaired skin integrity
d.
Chronic pain
ANS: C
After the assessment is completed and the information that the patient has a Stage IV pressure ulcer is
gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for
an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain do not
support the current data in the question.
DIF:Understand (comprehension)REF:1199-1201
OBJ:List nursing diagnoses associated with impaired skin integrity.
TOP
lanningMSC:Management of Care
30. The nurse collects the following assessment data: right heel with reddened area that does not blanch.
Which nursing diagnosis will the nurse assign to this patient?
a.
Imbalanced nutrition: less than body requirements
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b.
Ine᯿అective peripheral tissue perfusion
c.
Risk for infection
d.
Acute pain
ANS: B
The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has
resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ine᯿అective peripheral
tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition do not support the data in the question.
DIF:Understand (comprehension)REF:1200
OBJ:List nursing diagnoses associated with impaired skin integrity.
TOP
iagnosisMSC:Management of Care
31. The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure
ulcers. Which action will the nurse take ᯿贄rst?
a.
O꥿ᖈer favorite 㔪uids.
b.
Turn the patient every 2 hours.
c.
Determine the patient’s risk factors.
d.
Encourage increased quantities of carbohydrates and fats.
ANS: C
The 흿rst step in prevention is to assess the patient’s risk factors for pressure ulcer development. When a
patient is immobile, the major risk to the skin is the formation of pressure ulcers. Nursing interventions focus
on prevention. O꥿ᖈering favorite 㔪uids, turning, and increasing carbohydrates and fats are not the 흿rst steps.
Determining risk factors is 흿rst so interventions can be implemented to reduce or eliminate those risk factors.
DIF:Apply (application)REF:1203 | 1221
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OBJ:Complete an assessment for a patient with impaired skin integrity.
TOP: Implementation MSC: Health Promotion and Maintenance
32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. Which
health care team member will the nurse consult?
a.
Respiratory therapist
b.
Registered dietitian
c.
Case manager
d.
Chaplain
ANS: B
Refer patients with pressure ulcers to the dietitian for early intervention for nutritional problems. Adequate
calories, protein, vitamins, and minerals promote wound healing for the impaired skin integrity. The nurse is
the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the
patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case
management can be consulted when the patient has a discharge need. A chaplain can be consulted when the
patient has a spiritual need.
DIF:Apply (application)REF:1208
OBJ: Develop a nursing care plan for a patient with impaired skin integrity.
TOP:ImplementationMSC:Management of Care
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. Which is the best goal for this patient?
a.
The patient will state what to look for with regard to an infection.
b.
The patient’s family will demonstrate speci흿c care of the wound site.
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c.
The patient’s family members will wash their hands when visiting the patient.
d.
The patient will remain free of odorous or purulent drainage from the wound.
ANS: D
Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at
increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection,
including an increase in temperature, an increase in white count, and odorous and purulent drainage from the
wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection. It is
important for the patient’s family to be able to demonstrate how to care for the wound and wash their hands,
but these statements are not goals or outcomes for this nursing diagnosis.
DIF:Apply (application)REF:1200 | 1201
OBJ: Develop a nursing care plan for a patient with impaired skin integrity.
TOP
lanningMSC:Management of Care
34. The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive
personnel?
a.
Assessing a surgical patient for risk of pressure ulcers
b.
Applying an elastic bandage to a medical-surgical patient
c.
Treating a pressure ulcer on the buttocks of a medical patient
d.
Implementing negative-pressure wound therapy on a stable patient
ANS: B
Applying an elastic bandage to a medical-surgical patient can be delegated to the nursing assistive personnel
(NAP). Assessing pressure ulcer risk, treating a pressure ulcer, and implementing negative-pressure wound
therapy cannot be delegated to an NAP.
DIF:Apply (application)REF:1236
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OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP:ImplementationMSC:Management of Care
35. The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and
removed the old dressing. In which order will the nurse implement the steps, starting with the 흿rst one?
1. Apply sterile gloves.
2. Cover and secure topper dressing.
3. Assess wound and surrounding skin.
4. Moisten gauze with prescribed solution.
5. Gently wring out excess solution and unfold.
6. Loosely pack until all wound surfaces are in contact with gauze.
a.
4, 3, 1, 5, 6, 2
b.
1, 3, 4, 5, 6, 2
c.
4, 1, 3, 5, 6, 2
d.
1, 4, 3, 5, 6, 2
ANS: B
The steps for a moist-to-dry dressing are as follows: (1) Apply sterile gloves; (2) assess appearance of
surrounding skin; (3) moisten gauze with prescribed solution. (4) Gently wring out excess solution and unfold;
apply gauze as single layer directly onto wound surface. (5) If wound is deep, gently pack dressing into wound
base by hand until all wound surfaces are in contact with gauze; (6) cover with sterile dry gauze and secure
topper dressing.
DIF:Apply (application)REF:1228-1229
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
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TOP: Implementation MSC: Basic Care and Comfort
36. The nurse is caring for a patient who has su꥿ᖈered a stroke and has residual mobility problems. The patient
is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk?
a.
Use gentle cleansers, and thoroughly dry the skin.
b.
Use therapeutic bed and mattress.
c.
Use absorbent pads and garments.
d.
Use products that hold moisture to the skin.
ANS: A
Use cleansers with nonionic surfactants that are gentle to the skin. After you clean the skin, make sure that it is
completely dry. Absorbent pads and garments are controversial and should be considered only when other
alternatives have been exhausted. Depending on the needs of the patient, a specialty bed may be needed, but
again, this does not provide the initial defense for skin breakdown. Use only products that wick moisture away
from the patient’s skin.
DIF:Apply (application)REF:1203-1204
OBJ: Develop a nursing care plan for a patient with impaired skin integrity.
TOP: Implementation MSC: Reduction of Risk Potential
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?
a.
At least 3 hours
b.
Less than 2 hours
c.
No longer than 30 minutes
d.
As long as the patient remains comfortable
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ANS: B
When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair
sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than
in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Sitting for longer than 2 hours can
increase the chance of ischemia.
DIF:Apply (application)REF:1204
OBJ: Develop a nursing care plan for a patient with impaired skin integrity.
TOP: Planning MSC: Reduction of Risk Potential
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. Which is the best method for repositioning the patient?
a.
Place the patient in a 30-degree supine position.
b.
Utilize a transfer device to lift the patient.
c.
Elevate the head of the bed 45 degrees.
d.
Slide the patient into the new position.
ANS: B
When repositioning the patient, obtain assistance and utilize a transfer device to lift rather than drag the
patient. Sliding the patient into the new position will increase friction. The patient should be placed in a 30degree lateral position, not a supine position. The head of the bed should be elevated less than 30 degrees to
prevent pressure ulcer development from shearing forces.
DIF:Apply (application)REF:1204
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Basic Care and Comfort
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39. A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to
air and does not apply a dressing. To which patient did the nurse provide care?
a.
A patient with a clean Stage I
b.
A patient with a clean Stage II
c.
A patient with a clean Stage III
d.
A patient with a clean Stage IV
ANS: A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a
dressing. A composite 흿lm, hydrocolloid, or hydrogel can be utilized on a clean Stage II. A hydrocolloid,
hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage III. Hydrogel covered
with foam, calcium alginate, and gauze can be utilized with a clean Stage IV. An unstageable wound covered
with eschar should utilize a dressing of adherent 흿lm or gauze with an ordered solution of enzymes.
DIF:Understand (comprehension)REF:1211
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Physiological Adaptation
40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to
change the dressing. Which action should the nurse take?
a.
Turn on the television.
b.
Explain the procedure.
c.
Tell the patient “Close your eyes.”
d.
Ask the family to leave the room.
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ANS: B
Explaining the procedure educates the patient regarding the dressing change and involves him in the care,
thereby allowing the patient some control in decreasing anxiety. Telling the patient to close the eyes and
turning on the television are distractions that do not usually decrease a patient’s anxiety. If the family is a
support system, asking support systems to leave the room can actually increase a patient’s anxiety.
DIF:Apply (application)REF:1232
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Psychosocial Integrity
41. The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be
included?
a.
Allow the solution to 㔪ow from the most contaminated to the least contaminated.
b.
Scrub vigorously when applying noncytotoxic solution to the skin.
c.
Cleanse in a direction from the least contaminated area.
d.
Utilize clean gauze and clean gloves to cleanse a site.
ANS: C
Cleanse in a direction from the least contaminated area, such as from the wound or incision, to the
surrounding skin. While cleansing surgical or traumatic wounds by applying noncytotoxic solution with sterile
gauze or by irrigations is correct, vigorous scrubbing is inappropriate and can cause damage to the skin. Use
gentle friction when applying solutions to the skin, and allow irrigation to 㔪ow from the least to the most
contaminated area.
DIF:Apply (application)REF:1213-1214
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Reduction of Risk Potential
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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. Which is the best explanation for the nurse to use when
teaching the patient the reason for the binder?
a.
It reduces edema at the surgical site.
b.
It secures the dressing in place.
c.
It immobilizes the abdomen.
d.
It supports the abdomen.
ANS: D
The patient has a large abdominal incision. This incision will need support, and an abdominal binder will
support this wound, especially during movement, as well as during deep breathing and coughing. A binder can
be used to immobilize a body part (e.g., an elastic bandage applied around a sprained ankle). A binder can be
used to prevent edema, for example, in an extremity but in this case is not used to reduce edema at a surgical
site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.
DIF:Understand (comprehension)REF:1208 | 1213 | 1216
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Teaching/Learning MSC: Basic Care and Comfort
43. The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the
nurse take to assist with pain management?
a.
Monitor vital signs every 15 minutes.
b.
Check pulses in the right foot.
c.
Keep the leg dependent.
d.
Apply ice.
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ANS: D
Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation (not
dependent) assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes
is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases
pain. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain
management intervention.
DIF:Apply (application)REF:1219-1220
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Basic Care and Comfort
44. The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has
implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin
breakdown is removed?
a.
12
b.
13
c.
20
d.
23
ANS: D
The best sign is a perfect score of 23. The Braden Scale is composed of six subscales: sensory perception,
moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower
total score indicates a higher risk for pressure ulcer development. The cuto꥿ᖈ score for onset of pressure ulcer
risk with the Braden Scale in the general adult population is 18.
DIF:Analyze (analysis)REF:1192
OBJ:State evaluation criteria for a patient with impaired skin integrity.
TOP: Evaluation MSC: Reduction of Risk Potential
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MULTIPLE RESPONSE
1. The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take?
(Select all that apply.)
a.
Place moist sterile gauze over the site.
b.
Gently place the organs back.
c.
Contact the surgical team.
d.
O꥿ᖈer a glass of water.
e.
Monitor for shock.
ANS: A, C, E
The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical
emergency. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the
patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for
emergency surgery.
DIF:Understand (comprehension)REF:1192
OBJ: Describe complications of wound healing. TOP: Implementation
MSC: Physiological Adaptation
2. The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse
monitor for in this patient? (Select all that apply.)
a.
Hemostasis
b.
Maturation
c.
In㔪ammatory
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d.
Proliferative
e.
Reproduction
f.
Reestablishment of epidermal layers
ANS: A, B, C, D
The four phases involved in the healing process of a full-thickness wound are hemostasis, in㔪ammatory,
proliferative, and maturation. Three components are involved in the healing process of a partial-thickness
wound: in㔪ammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of
the epidermal layers.
DIF:Understand (comprehension)REF:1191
OBJ:Explain the factors that impede or promote wound healing.
TOP: Assessment MSC: Physiological Adaptation
3. 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.)
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.
“What medications do you take?”
e.
“Is movement painful?”
f.
“Have you ever fallen?”
ANS: A, B, C, E
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Changing positions is important for decreasing the pressure associated with long periods of time in the same
position. If the patient is able to feel heat or cold and is mobile, she can protect herself by withdrawing from
the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in
contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems
with painful movement will alert the nurse to any potential for decreased movement and increased risk for skin
breakdown. Medications and falling are safety risk questions.
DIF:Understand (comprehension)REF:1196
OBJ:Complete an assessment for a patient with impaired skin integrity.
TOP: Assessment MSC: Reduction of Risk Potential
4. The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in
the skin assessment? (Select all that apply.)
a.
Vision
b.
Hyperemia
c.
Induration
d.
Blanching
e.
Temperature of skin
ANS: B, C, D, E
Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and palpate for
blanching or nonblaching. Early signs of skin damage include induration, bogginess (less-than-normal sti꥿ᖈness),
and increased warmth at the injury site compared to nearby areas. Changes in temperature can indicate
changes in blood 㔪ow to that area of the skin. Vision is not included in the skin assessment.
DIF:Apply (application)REF:1186 | 1196
OBJ:Complete an assessment for a patient with impaired skin integrity.
TOP:AssessmentMSC:Health Promotion and Maintenance
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5. The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder.
Which actions will the nurse take before applying the bandage and binder? (Select all that apply.)
a.
Cover exposed wounds.
b.
Mark the sites of all abrasions.
c.
Assess the condition of current dressings.
d.
Inspect the skin for abrasions and edema.
e.
Cleanse the area with hydrogen peroxide.
f.
Assess the skin at underlying areas for circulatory impairment.
ANS: A, C, D, F
Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect
the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for
covering exposed wounds or open abrasions with a dressing and assessing the condition of underlying
dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the
bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages
are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean,
and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can
interfere with wound healing.
DIF:Understand (comprehension)REF:1216
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Basic Care and Comfort
6. The nurse is updating the plan of care for a patient with impaired skin integrity. Which 흿ndings indicate
achievement of goals and outcomes? (Select all that apply.)
a.
The patient’s expectations are not being met.
b.
Skin is intact with no redness or swelling.
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c.
Nonblanchable erythema is absent.
d.
No injuries to the skin and tissues are evident.
e.
Granulation tissue is present.
ANS: B, C, D, E
Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying
tissues, and restore skin integrity. Skin intact, nonblanchable erythema absent, no injuries, and presence of
granulation tissue are all 흿ndings indicating achievement of goals and outcomes. The patient’s expectations not
being met indicates no progression toward goals/outcomes.
DIF:Analyze (analysis)REF:1220
OBJ:State evaluation criteria for a patient with impaired skin integrity.
TOP:EvaluationMSC:Management of Care
MATCHING
The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its
description.
a.
Absorbs drainage through the use of exudate absorbers in the dressing
b.
Very soothing to the patient and do not adhere to the wound bed
c.
Barrier to external 㔪uids/bacteria but allows wound to “breathe”
d.
Manufactured from seaweed and comes in sheet and rope form
e.
Oldest and most common absorbent dressing
1. Gauze
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2. Transparent
3. Hydrocolloid
4. Hydrogel
5. Calcium alginate
1.ANS:EDIF:Understand (comprehension)REF:1209-1210 | 1211
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Basic Care and Comfort
2.ANS:CDIF:Understand (comprehension)REF:1209-1210 | 1211
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Basic Care and Comfort
3.ANS:ADIF:Understand (comprehension)REF:1209-1210 | 1211
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Basic Care and Comfort
4.ANS:BDIF:Understand (comprehension)REF:1209-1210 | 1211
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Basic Care and Comfort
5.ANS
DIF:Understand (comprehension)REF:1209-1210 | 1211
OBJ: List appropriate nursing interventions for a patient with impaired skin integrity.
TOP: Implementation MSC: Basic Care and Comfort
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