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Fundamentals of Nursing Chapter 48: Skin Integrity
and Wound Care Practice questions and correct
answers
1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care
understands the need for a multidisciplinary approach. The nurse evaluates the need for several
consults. Which of the following should always be included in the consults? (Select all that apply.)
a. Registered dietitian
b. Enterostomal and wound care nurse
c. Physical therapist
d. Case management personnel
e. Chaplain
f. Pharmacist - ------------correct answer----------ANS: A, B, C, D
A registered dietitian is useful in working with the nurse to determine a meal plan that will support
wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient
with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile
patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long
time to heal and usually require continued therapy in the home. Case management personnel are useful
in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can
assist. If the patient has a need associated with medications, the pharmacist can assist. However,
chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special
need arises.
1. The nurse is working on a medical-surgical unit that has been participating in a research project
associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to
pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain. - ------------correct answer----------ANS: B
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
Document shared on https://www.docsity.com/en/docs/fundamentals-of-nursing-chapter-48-skin-integrity-and-wound-care-practice-questions-and-c/15715166/
, 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 a diet low in calories and fat are not included among the predisposing factors.
10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse
recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention. - ------------correct answer----------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 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 filled with scar tissue. It takes longer for a wound to heal by
secondary intention; thus the chance of infection is greater.
11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention. - ------------correct answer----------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 filled 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 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 several days, and then the wound edges are approximated. Wound closure is
delayed until the risk of infection is resolved.
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12. Which nursing observation would indicate that a wound healed by secondary intention?
a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at site
d. Scarring can be severe. - ------------correct answer----------ANS: D
A wound healing by secondary intention takes longer than one healing by primary intention. The wound
is left open until it becomes filled 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.
13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing
observation would indicate that the patient was experiencing a complication of wound healing?
a. The incision site has started to itch.
b. The incision site is approximated.
c. The patient has pain at the incision site.
d. The incision has a mass, bluish in color. - ------------correct answer----------ANS: D
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
flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing
process. Incisions should be approximated with edges together. After surgery, when nerves in the skin
and tissues have been traumatized by the surgical procedure, it is expected that the patient would
experience pain.
14. Which of these findings if seen in a postoperative patient should the nurse associate with
dehiscence?
a. Complaint by patient that something has given way
b. Protrusion of visceral organs through a wound opening
c. Chronic drainage of fluid through the incision site
d. Drainage that is odorous and purulent - ------------correct answer----------ANS: A
occurs is when a wound 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. Patients often report feeling as though something has given way. Evisceration is seen when vital
organs protrude through a wound opening. A fistula is an abnormal passage between two organs or
Document shared on https://www.docsity.com/en/docs/fundamentals-of-nursing-chapter-48-skin-integrity-and-wound-care-practice-questions-and-c/15715166/
Fundamentals of Nursing Chapter 48: Skin Integrity
and Wound Care Practice questions and correct
answers
1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care
understands the need for a multidisciplinary approach. The nurse evaluates the need for several
consults. Which of the following should always be included in the consults? (Select all that apply.)
a. Registered dietitian
b. Enterostomal and wound care nurse
c. Physical therapist
d. Case management personnel
e. Chaplain
f. Pharmacist - ------------correct answer----------ANS: A, B, C, D
A registered dietitian is useful in working with the nurse to determine a meal plan that will support
wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient
with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile
patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long
time to heal and usually require continued therapy in the home. Case management personnel are useful
in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can
assist. If the patient has a need associated with medications, the pharmacist can assist. However,
chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special
need arises.
1. The nurse is working on a medical-surgical unit that has been participating in a research project
associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to
pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain. - ------------correct answer----------ANS: B
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
Document shared on https://www.docsity.com/en/docs/fundamentals-of-nursing-chapter-48-skin-integrity-and-wound-care-practice-questions-and-c/15715166/
, 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 a diet low in calories and fat are not included among the predisposing factors.
10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse
recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention. - ------------correct answer----------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 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 filled with scar tissue. It takes longer for a wound to heal by
secondary intention; thus the chance of infection is greater.
11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention. - ------------correct answer----------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 filled 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 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 several days, and then the wound edges are approximated. Wound closure is
delayed until the risk of infection is resolved.
Document shared on https://www.docsity.com/en/docs/fundamentals-of-nursing-chapter-48-skin-integrity-and-wound-care-practice-questions-and-c/15715166/
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12. Which nursing observation would indicate that a wound healed by secondary intention?
a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at site
d. Scarring can be severe. - ------------correct answer----------ANS: D
A wound healing by secondary intention takes longer than one healing by primary intention. The wound
is left open until it becomes filled 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.
13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing
observation would indicate that the patient was experiencing a complication of wound healing?
a. The incision site has started to itch.
b. The incision site is approximated.
c. The patient has pain at the incision site.
d. The incision has a mass, bluish in color. - ------------correct answer----------ANS: D
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
flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing
process. Incisions should be approximated with edges together. After surgery, when nerves in the skin
and tissues have been traumatized by the surgical procedure, it is expected that the patient would
experience pain.
14. Which of these findings if seen in a postoperative patient should the nurse associate with
dehiscence?
a. Complaint by patient that something has given way
b. Protrusion of visceral organs through a wound opening
c. Chronic drainage of fluid through the incision site
d. Drainage that is odorous and purulent - ------------correct answer----------ANS: A
occurs is when a wound 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. Patients often report feeling as though something has given way. Evisceration is seen when vital
organs protrude through a wound opening. A fistula is an abnormal passage between two organs or
Document shared on https://www.docsity.com/en/docs/fundamentals-of-nursing-chapter-48-skin-integrity-and-wound-care-practice-questions-and-c/15715166/
