Chapter 29: Skin Integrity and Wound Care
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative Practice, 2nd Edition
MULTIPLE CHOICE
1. The nurse knows which description would be classified as a closed wound?
a. A large bruise on the side of the face
b. A surgical incision that is sutured closed
c. A puncture wound that is healing
d. An abrasion on the leg
ANS: A
In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin’s
surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.
DIF: Applying
OBJ: 29.3
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
2. The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further
education?
a. “The wound will be red.”
b. “The wound will have pus.”
c. “The wound will be warm.”
d. “The wound will need to be treated.”
ANS: B
An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be
purulent (contain pus), and has a bacterial count in the tissue of at least 10 5/g of tissue sampled when cultured. The wound will
need to be treated for the infection.
DIF: Applying
OBJ: 29.3
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
3. The nurse identifies which type of wounds heal by tertiary intention?
a. An acute wound in which the patient has sutures placed when it happened.
b. A pressure ulcer that was treated with dressing changes and is healed.
c. An acute wound in which surgical glue was used to close the wound.
d. A wound that was left open initially and closed later with sutures.
ANS: D
When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as
surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are
examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention,
new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure
ulcer.
DIF: Applying
OBJ: 29.3
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
4. The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a
“popping sensation” and a wetness in the dressing, the nurse immediately suspects which complication?
a. A wound infection
b. The stitches came loose
c. Wound dehiscence
d. Wound crepitus
ANS: C
Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue
layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation.
Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.
DIF: Analyzing
OBJ: 29.3
TOP: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
Copyright © 2020, Elsevier Inc. All Rights Reserved.
1
5. The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when
the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?
a. Cover the wound with a sterile gauze pad.
b. Cover the wound with a transparent dressing.
c. Put pressure on the wound with a sterile gauze pad.
d. Cover the wound with gauze soaked with normal saline.
ANS: D
If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the surgeon
immediately. Putting pressure on the wound could cause further complications. Transparent films are used for autolytic
debridement. A gauze pad will allow the wound to become dry and cause further complications.
DIF: Analyzing
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
6. The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing
diagnosis of Impaired skin integrity?
a. Wound will be completely healed in 72 hours.
b. Wound will show signs of healing within 2 weeks.
c. Patient will develop no new pressure ulcers.
d. Patient will ambulate twice a day.
ANS: B
A stage 3 pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of
healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and
ambulating twice a day is more of an intervention.
DIF: Applying
OBJ: 29.5
TOP: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
7. A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to
intervene?
a. The nurse asks the UAP to assess the wound.
b. The nurse asks the UAP to report increased wound drainage.
c. The nurse asks the UAP to observe changes in dietary intake.
d. The nurse asks the UAP to change the dressing.
ANS: A
Assessment and evaluation of a patient’s skin and wounds, and the effectiveness of the treatment plan, are a nurse’s responsibility
and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or
integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary
intake. Some dressing changes can be performed by UAP in some situations.
DIF: Applying
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
8. The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse
should place the head of the bed in which position?
a. Flat
b. 90 degrees
c. 30 degrees
d. 45 degrees
ANS: C
When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on
bony prominences such as the head of the trochanter.
DIF: Applying
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
9. The nurse recognizes which intervention is not a form of mechanical debridement?
a. Wet to dry dressings
b. Whirlpool baths
c. Wet to damp dressing
d. Enzymatic dressing
ANS: D
Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the
fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective
form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may
be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.
DIF: Understanding
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
Copyright © 2020, Elsevier Inc. All Rights Reserved.
2
10. The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a
lack of understanding?
a. “Occlusive dressings are used for autolytic debridement.”
b. “Hydrocolloids are a type of occlusive dressing.”
c. “Occlusive dressings can be used on infected wounds.”
d. “Occlusive dressings support the most comfortable form of debridement.”
ANS: C
Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and are contraindicated in
infected wounds. It is the most comfortable form of debridement for the patient.
DIF: Applying
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
11. The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?
a. A wound with a large amount of drainage
b. A wound that is tunneling
c. A postsurgical incision with staples
d. A wound with a moderate amount of drainage
ANS: D
Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose. They absorb a small to
moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed. A wound with a large amount of
drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a
wound that is tunneling may require packing.
DIF: Applying
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
12. When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?
a. The drain must be compressed after emptying to work properly.
b. The drain must be connected to suction if ordered.
c. The drain is not sutured in place so care is taken to not dislodge it.
d. The suction pulls drainage away from the wound as it re-expands.
ANS: C
The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction.
Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.
DIF: Applying
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
13. The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for
further education?
a. “I should fill my ice bag 2/3 full of ice.”
b. “I should use distilled water in my Aqua-K pad.”
c. “I can warm up my hot pack in the microwave.”
d. “I should check the order for how long to leave the compress on.”
ANS: C
Warm compresses and water for soaks should not be heated in the microwave unless the product and microwave are specifically
designed for this type of heating. Ice bags are filled two-thirds full, distilled water is used in Aqua-K pads, and application time for
heat is as stated in the PCP order (for cold, it is a maximum of 20 to 30 minutes).
DIF: Applying
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
14. The nurse identifies which syringe to use when irrigating a patient’s deep wound?
a. 5-mL syringe
b. 10-mL syringe
c. 3-mL syringe
d. 30-mL syringe
ANS: D
A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi)
of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been
shown to achieve an irrigation force that falls within the recommended 4 to 15 psi.
DIF: Understanding
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
Copyright © 2020, Elsevier Inc. All Rights Reserved.
3
15. The nurse understands which rationale to be appropriate for drying a wound after irrigation?
a. Ensure the new dressing adheres to the wound.
b. Ensure the new dressing remains occlusive.
c. Prevent skin breakdown from moisture.
d. Prevent infection from irrigate solution.
ANS: C
Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being
removed and reduces trauma to the wound. The type of dressing will determine how it lays in the wound and whether it is
occlusive. The drying does not prevent infection.
DIF: Understanding
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
16. The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the
nurse do first?
a. Notify the provider.
b. Notify the wound care nurse.
c. Stop the procedure.
d. Give the patient pain medication.
ANS: C
If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or
preexisting. Then the nurse can determine what to do next based on the patient’s response.
DIF: Analyzing
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
17. The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired
physical mobility?
a. Patient will remain free of wound infections during the hospitalization.
b. Patient will report pain management strategies and reduce pain to a tolerable
level.
c. Patient will be able to assist with position changes using over bed trapeze within 1
week.
d. Patient will consume adequate nutrition to meet nutritional requirements within 1
week.
ANS: C
Patient will be able to assist with position changes using over bed trapeze within 1 week is an appropriate goal for impaired
mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for impaired tissue
integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for acute pain.
The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Impaired
nutritional status.
DIF: Applying
OBJ: 29.5
TOP: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
18. When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?
a. A pressure ulcer that involves exposure of bone and connective tissue.
b. A pressure ulcer that does not extend through the fascia.
c. A pressure ulcer that does not include tunneling.
d. A partial-thick wound that involves the epidermis.
ANS: B
Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to
muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve
exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage 2 pressure ulcers are partial-thickness wounds
that involve the epidermis and/or dermis.
DIF: Understanding
OBJ: 29.3
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
19. The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?
a. Stratum germinativum
b. Epidermis
c. Subcutaneous layer
d. Stratum corneum
ANS: C
The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum
germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum
corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer
of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.
DIF: Understanding
OBJ: 29.1
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
Copyright © 2020, Elsevier Inc. All Rights Reserved.
4
MULTIPLE RESPONSE
1. The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing? (Select all that
apply.)
a. A patient who has diabetes.
b. A patient with COPD.
c. A patient with on bed rest who is repositioned.
d. A patient who is obese and sweats excessively.
e. A patient on long-term steroid therapy.
ANS: A, B, C, D, E
Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular
disease, which impacts the skin’s ability to obtain required oxygen and nutrients, or diabetes, which affects not only the
microvasculature, but also the skin’s normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids,
and vitamins and minerals; medications such as steroids, nonsteroidal, anti-inflammatories, and anticoagulants; excessive moisture
from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.
DIF: Applying
OBJ: 29.2
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
2. The nurse recognizes that the cause of pressure ulcers includes which factors? (Select all that apply.)
a. Intensity of the pressure
b. Duration of the pressure
c. Tissue’s ability to tolerate the pressure
d. Person’s age
e. Person’s nutritional status
ANS: A, B, C, D, E
The primary cause of pressure ulcers is, as the name suggests, pressure. However, it is more than just pressure; it is the intensity of
the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue’s
ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.
DIF: Applying
OBJ: 29.2
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
3. When the nurse is performing a focused wound assessment on a patient, what information should be included in the
documentation? (Select all that apply.)
a. Location and size
b. Characteristics of the wound bed
c. Patient’s response to wound treatment
d. Patient’s pain level
e. Presence of drainage
ANS: A, B, C, E
A focused wound assessment includes an evaluation of the wound’s location, size, and color; presence of drainage; condition of the
wound edges; characteristics of the wound bed; and patient’s response to the wound or wound treatment. The patient’s pain level
would be documented with his/her pain assessment.
DIF: Applying
OBJ: 29.3
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
4. The nurse is using the Braden scale to assess the patient’s risk for a pressure ulcer. Which risk categories are associated with the
Braden scale? (Select all that apply.)
a. Activity
b. Friction and shear
c. Moisture
d. Sensory perception
e. Cognition
ANS: A, B, C, D
The Braden scale ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction
and shear. The scale does not include cognition.
DIF: Understanding
OBJ: 29.3
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
Copyright © 2020, Elsevier Inc. All Rights Reserved.
5
5. The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions will the nurse
perform? (Select all that apply.)
a. Measure the amount of drainage in the device prior to emptying.
b. Label each drain and record them separately.
c. Recompress the device after emptying.
d. Secure the device to the patient’s gown above the level of the wound.
e. Check for kinks in the tubing.
ANS: B, C, E
Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement
of the drainage. After emptying, recompress the device to maintain suction. Secure the container(s) to the patient’s hospital gown
below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label
them and document observations by the drain label.
DIF: Applying
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
6. The nurse recognizes that cold therapy is contraindicated in which conditions? (Select all that apply.)
a. Edema
b. Shivering
c. Bleeding
d. Circulatory problems
e. Advanced age
ANS: A, B, D
Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory
pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (thi s is a comfort
concern). Bleeding is contraindicated in heat therapy. Advanced age would require frequent observation due to thin skin.
DIF: Understanding
OBJ: 29.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
Copyright © 2020, Elsevier Inc. All Rights Reserved.
6