answers
Tissue damage underlying intact skin around wound margins is referred to as: - * * VERIFIED
ANSWERS **✔✔Undermining
A patient presents with a chronic erythematous traumatic wound on the anterior lower leg.
Current care includes use of mupirocin (Bactroban) cream and a four-layer compression
wrap. Hypergranulation tissue is present in the wound bed. Which modification should be
made to this patient's treatment program? - ** VERIFIED ANSWERS **✔✔Use foam dressing
on the wound
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provide Test banks and other E books to students - ** VERIFIED ANSWERS **✔✔
Hypergranulation tissue - ** VERIFIED ANSWERS **✔✔excessive, soft, flaccid granulating
tissue that is raised above the level of the periwound tissue, preventing proper
epithelization, and may reflect excess moisture in the wound
Which of the following is MOST effective in protecting the surrounding skin of a draining
wound? - ** VERIFIED ANSWERS **✔✔Alcohol-free skin sealant
Under which circumstance is negative-pressure wound therapy (NPWT)
CONTRAINDICATED? - ** VERIFIED ANSWERS **✔✔Unexplored fistula
Contraindications for NPWT - ** VERIFIED ANSWERS **✔✔-Wound malignancy
-Untreated osteomyelitis
-Exposed blood vessels and organs
-Non-enteric, unexplored fistulas
, Normal ABI - ** VERIFIED ANSWERS **✔✔1-1.4
A new patient has an arterial ulcer from a fall 2 months ago that is increasing in size. The
patient shares that glucose levels each morning average 138. The Certified Wound Care
Nurse (CWCN) completes an ankle-brachial index and calculates a score of 1.0. Pedal pulses
are diminished. The wound is pale pink with serous drainage and measures 3 cm. x 5 cm. x
0.3 cm. Which referral will MOST likely increase wound healing success for this patient? - * *
VERIFIED ANSWERS **✔✔Vascular surgery
Which wound and dressing combination is MOST appropriate to promote autolytic
debridement? - ** VERIFIED ANSWERS **✔✔A wound with slough and hydrocolloid
dressing
Autolytic debridement - ** VERIFIED ANSWERS **✔✔-Using the body's enzymes and WBCs
to debride the wound
-Requires secondary dressing covering (hydrocolloids, alginates, hydrogels, and transparent
films)
A Certified Wound Care Nurse (CWCN) is teaching a hospital orientation for new nurse
graduates and is discussing prevention of pressure injuries. One nurse asks the CWCN
about a patient who developed a deep tissue injury 3 days after admission even after going to
extremes to relieve pressure. The CWCN takes this opportunity to teach the importance of
each assessment related to deep tissue injury development. What information can the
CWCN provide to the nurse? - ** VERIFIED ANSWERS **✔✔Irreversible skin damage can
occur within a few hours but may not be visible for 2-5 days
A 45-year-old patient with paraplegia from a motor vehicle accident 3 years ago has stage 3
pressure injuries to the greater trochanters bilaterally. The patient was hospitalized
secondary to appendicitis and is preparing for discharge. Which outpatient referral should
the Certified Wound Care Nurse (CWCN) recommend FIRST at the visit? - ** VERIFIED
ANSWERS **✔✔Physical therapy for wheelchair evaluation