Skin Integrity and Wound Care Written Exam with Correct Answers.
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure ulcer? a) Use pillows to maintain a side-lying position as needed.
b) Elevate the head of the bed 90 degrees. c) Place a foot board on the bed. d) Provide incontinent care every 4 hours as needed. - CORRECT ANSWER Use pillows to maintain a side-
lying position as needed.
Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and
alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation to the skin. A foot board prevents footdrop in clients but does not decrease the risk for pressure ulcers.
The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching? a) "I will not remove the staples myself." b) "I may have staples in place for a number of days." c) "After delivery, I will have sutures in place." d) "Steri-Strips will hold my wound together until it heals." - CORRECT ANSWER "Steri-Strips will hold my wound together until it heals." After a Cesarean section, a client will be sutured and have staples put in place for a number of days. The healthcare provider or nurse will remove staples. Steri-Strips are not strong enough to hold this type of wound together.
A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound? a) Stage III b) Suspected deep tissue injury c) Stage II d) Unstageable - CORRECT ANSWER Suspected deep tissue injury
A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial thickness loss of dermis that often presents as an open blister. A stage III pressure ulcer is a full-thickness tissue loss in which subcutaneous tissue is visible. An unstageable wound is covered by slough or eschar. The depth of the wound is unknown because of this covering.
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a) An individual's skin changes little over the life span. b) In children younger than 2 years, the skin is thicker and stronger than in adults. c) A child's skin becomes less resistant to injury and infection as the child grows. d) An infant's skin and mucous membranes are easily injured and at risk for infection. - CORRECT ANSWER An infant's skin and mucous membranes are easily injured and at risk for infection.
An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure ulcer? a) Use pillows to maintain a side-lying position as needed.
b) Elevate the head of the bed 90 degrees. c) Place a foot board on the bed. d) Provide incontinent care every 4 hours as needed. - CORRECT ANSWER Use pillows to maintain a side-
lying position as needed.
Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and
alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation to the skin. A foot board prevents footdrop in clients but does not decrease the risk for pressure ulcers.
The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching? a) "I will not remove the staples myself." b) "I may have staples in place for a number of days." c) "After delivery, I will have sutures in place." d) "Steri-Strips will hold my wound together until it heals." - CORRECT ANSWER "Steri-Strips will hold my wound together until it heals." After a Cesarean section, a client will be sutured and have staples put in place for a number of days. The healthcare provider or nurse will remove staples. Steri-Strips are not strong enough to hold this type of wound together.
A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound? a) Stage III b) Suspected deep tissue injury c) Stage II d) Unstageable - CORRECT ANSWER Suspected deep tissue injury
A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial thickness loss of dermis that often presents as an open blister. A stage III pressure ulcer is a full-thickness tissue loss in which subcutaneous tissue is visible. An unstageable wound is covered by slough or eschar. The depth of the wound is unknown because of this covering.
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a) An individual's skin changes little over the life span. b) In children younger than 2 years, the skin is thicker and stronger than in adults. c) A child's skin becomes less resistant to injury and infection as the child grows. d) An infant's skin and mucous membranes are easily injured and at risk for infection. - CORRECT ANSWER An infant's skin and mucous membranes are easily injured and at risk for infection.
An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.
