NUR155 Unit 6 Skin Integrity and Wounds Quiz
Practice Questions ONLY
1. The nurse is assessing the perineal wound in a client who has returned from the operating room
following an abdominal perineal resection and notes serosanguineous drainage from the wound.
Which nursing intervention is most appropriate?
a. Notify the surgeon.
b. Clamp the surgical drain.
c. Change the dressing as prescribed.
d. Remove and replace the perineal packing.
2. The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which
areas helpful in assessing for pallor or cyanosis? Select all that apply.
a. Sclerae
b. Tongue
c. Nail beds
d. Elbows and heels
e. Mucous membranes
3. The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the
nurse best determine the presence of erythema?
a. Assess for drainage from the wound.
b. Assess for redness around the wound edges.
c. Palpate for swelling around the wound edges.
d. Palpate for increased skin temperature around the wound edges.
4. The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an
appropriate nursing intervention for this client?
a. Ensure that a sterile safety pin is through the drain.
b. Measure the amount of drainage in a measuring container.
c. Establish that the drain is at the prescribed amount of suction.
d. Squeeze the suction device and close the port after emptying the drain.
, 5. A client has a wound with a moderate amount of drainage and is scheduled for a dressing
change. Which dressing, if selected by the student nurse, requires further intervention by the
nursing instructor?
a. Foam
b. Alginate dressing
c. Hydrocolloid dressing
d. Semipermeable transparent film
6. The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which
dressing would the nurse expect to be prescribed in the treatment of this wound?
a. Hydrogel dressing
b. Transparent dressing
c. Antimicrobial dressing
d. Calcium alginate dressing
7. A client arriving at the emergency department has experienced frostbite to the right hand.
Which finding would the nurse note on assessment of the client's hand?
a. A pink edematous hand
b. Fiery red skin with edema in the nail beds
c. Black fingertips surrounded by an erythematous rash
d. A white color to the skin, which is insensitive to touch
8. The evening nurse reviews the nursing documentation in a client's chart and notes that the day
nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which
finding would the nurse expect to note on assessment of the client's sacral area?
a. Intact skin
b. Full-thickness skin loss
c. Exposed bone, tendon, or muscle
d. Partial-thickness skin loss of the dermis
9. The nurse is concerned about potential skin integrity problems for an unconscious client. Which
interventions would be most appropriate to include in the plan of care for this client? Select all
that apply.
a. Reposition every 2 hours.
b. Use a bed cradle as indicated.
Practice Questions ONLY
1. The nurse is assessing the perineal wound in a client who has returned from the operating room
following an abdominal perineal resection and notes serosanguineous drainage from the wound.
Which nursing intervention is most appropriate?
a. Notify the surgeon.
b. Clamp the surgical drain.
c. Change the dressing as prescribed.
d. Remove and replace the perineal packing.
2. The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which
areas helpful in assessing for pallor or cyanosis? Select all that apply.
a. Sclerae
b. Tongue
c. Nail beds
d. Elbows and heels
e. Mucous membranes
3. The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the
nurse best determine the presence of erythema?
a. Assess for drainage from the wound.
b. Assess for redness around the wound edges.
c. Palpate for swelling around the wound edges.
d. Palpate for increased skin temperature around the wound edges.
4. The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an
appropriate nursing intervention for this client?
a. Ensure that a sterile safety pin is through the drain.
b. Measure the amount of drainage in a measuring container.
c. Establish that the drain is at the prescribed amount of suction.
d. Squeeze the suction device and close the port after emptying the drain.
, 5. A client has a wound with a moderate amount of drainage and is scheduled for a dressing
change. Which dressing, if selected by the student nurse, requires further intervention by the
nursing instructor?
a. Foam
b. Alginate dressing
c. Hydrocolloid dressing
d. Semipermeable transparent film
6. The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which
dressing would the nurse expect to be prescribed in the treatment of this wound?
a. Hydrogel dressing
b. Transparent dressing
c. Antimicrobial dressing
d. Calcium alginate dressing
7. A client arriving at the emergency department has experienced frostbite to the right hand.
Which finding would the nurse note on assessment of the client's hand?
a. A pink edematous hand
b. Fiery red skin with edema in the nail beds
c. Black fingertips surrounded by an erythematous rash
d. A white color to the skin, which is insensitive to touch
8. The evening nurse reviews the nursing documentation in a client's chart and notes that the day
nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which
finding would the nurse expect to note on assessment of the client's sacral area?
a. Intact skin
b. Full-thickness skin loss
c. Exposed bone, tendon, or muscle
d. Partial-thickness skin loss of the dermis
9. The nurse is concerned about potential skin integrity problems for an unconscious client. Which
interventions would be most appropriate to include in the plan of care for this client? Select all
that apply.
a. Reposition every 2 hours.
b. Use a bed cradle as indicated.
