Skin Integrity & Wound Care - NCLEX
Style Questions and Answers Graded A+
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no
necrotic areas. The nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing indicated. - ANSWER-3. Hydrocolloid; Hydrocolloid dressings protect
shallow ulcers and maintain an appropriate healing environment.
Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2)
will stick to granulation tissue, causing more damage. A dressing is needed to protect
the wound and enhance healing.
A client is admitted to the Emergency Department after a motorcycle accident that
resulted in the client's skidding across a cement parking lot. Since the client was
wearing shorts, there are large areas on the legs where the skin is ripped off. This
wound is best described as:
1. Abrasion
2. Unapproximated
3. Laceration
4. Eschar - ANSWER-3. Laceration; Laceration best describes the wound, because skin
is ripped off. An abrasion is a scrape. Unapproximated is a general term for a wound
that is not closed. Eschar is a scab-like covering over a wound.
A client's family asks you to explain some keloid scars that the client developed. The
best explanation of the keloid scars would be that keloid scars are:
1. Due to a relatively rare inherited tendency.
2. Caused by an abnormal amount of collagen being laid down in scar formation.
3. Most common in pale-skinned people of Northern European ancestry.
4. Caused by repeated and abrupt early disruption of eschar being formed. - ANSWER-
2. Caused by an abnormal amount of collagen being laid down in scar formation; Keloid
scars are due to an abnormal amount of collagen being laid down in scar formation in
the maturation phase, and they are more apt to occur in a dark-skinned person.
A client's wound is draining thick yellow material. The nurse correctly describes the
drainage as:
1. Sanguineous
, 2. Serous-sanguineous
3. Serous
4. Purulent - ANSWER-4. Purulent; Drainage is described as purulent. Sanguineous
and Serous-sanguineous contain blood. Serous is clear and watery.
A nurse is caring for patients with a variety of wounds. Which would will most likely heal
by primary intention?
1. Cut in the skin from a kitchen knife
2. Excoriated perineal area
3. Abrasion of the skin
4. Pressure ulcer - ANSWER-1. Cut in the skin from a kitchen knife; A cut in the skin by
a sharp instrument with minimal tissue loss can heal by primary intention when the
wound edges are lightly pulled together (approximated).
Excoriations, abrasions, and pressure ulcers heal by secondary, not primary. Secondary
intention healing occurs when wound edges are not approximated because of full-
thickness tissue loss; the wound is left open until it fills with new tissue. Abrasions and
excoriations are injuries to the surface of the skin.
A nurse is concerned about a client's ability to withstand exposure to pathogens. What
blood component should the nurse monitor? - ANSWER-Neutrophils; Neutrophils are
the most numerous leukocytes (white blood cells) and are a primary defense against
infection because they ingest and destroy microorganisms (phagocytosis).
An appropriate nursing diagnosis for a client with large areas of skin excoriation
resulting from scratching an allergic rash is:
1. Risk for Impaired Skin Integrity
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Infection - ANSWER-2. Impaired Skin Integrity; The client has an actual
impairment of the skin due to the rash and the scratching so is no longer "at risk".
Because the damage is at the skin level, it is not impaired tissue integrity (option 3)
since that would involve deeper tissues. Surface excoriation is also not prone to
becoming infected.
Black wounds are treated with debridement. Which type of debridement is most
selective and least damaging?
1. Debridement with scissors
2. Debridement with wet to dry dressings
3. Mechanical debridement
Style Questions and Answers Graded A+
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no
necrotic areas. The nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing indicated. - ANSWER-3. Hydrocolloid; Hydrocolloid dressings protect
shallow ulcers and maintain an appropriate healing environment.
Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2)
will stick to granulation tissue, causing more damage. A dressing is needed to protect
the wound and enhance healing.
A client is admitted to the Emergency Department after a motorcycle accident that
resulted in the client's skidding across a cement parking lot. Since the client was
wearing shorts, there are large areas on the legs where the skin is ripped off. This
wound is best described as:
1. Abrasion
2. Unapproximated
3. Laceration
4. Eschar - ANSWER-3. Laceration; Laceration best describes the wound, because skin
is ripped off. An abrasion is a scrape. Unapproximated is a general term for a wound
that is not closed. Eschar is a scab-like covering over a wound.
A client's family asks you to explain some keloid scars that the client developed. The
best explanation of the keloid scars would be that keloid scars are:
1. Due to a relatively rare inherited tendency.
2. Caused by an abnormal amount of collagen being laid down in scar formation.
3. Most common in pale-skinned people of Northern European ancestry.
4. Caused by repeated and abrupt early disruption of eschar being formed. - ANSWER-
2. Caused by an abnormal amount of collagen being laid down in scar formation; Keloid
scars are due to an abnormal amount of collagen being laid down in scar formation in
the maturation phase, and they are more apt to occur in a dark-skinned person.
A client's wound is draining thick yellow material. The nurse correctly describes the
drainage as:
1. Sanguineous
, 2. Serous-sanguineous
3. Serous
4. Purulent - ANSWER-4. Purulent; Drainage is described as purulent. Sanguineous
and Serous-sanguineous contain blood. Serous is clear and watery.
A nurse is caring for patients with a variety of wounds. Which would will most likely heal
by primary intention?
1. Cut in the skin from a kitchen knife
2. Excoriated perineal area
3. Abrasion of the skin
4. Pressure ulcer - ANSWER-1. Cut in the skin from a kitchen knife; A cut in the skin by
a sharp instrument with minimal tissue loss can heal by primary intention when the
wound edges are lightly pulled together (approximated).
Excoriations, abrasions, and pressure ulcers heal by secondary, not primary. Secondary
intention healing occurs when wound edges are not approximated because of full-
thickness tissue loss; the wound is left open until it fills with new tissue. Abrasions and
excoriations are injuries to the surface of the skin.
A nurse is concerned about a client's ability to withstand exposure to pathogens. What
blood component should the nurse monitor? - ANSWER-Neutrophils; Neutrophils are
the most numerous leukocytes (white blood cells) and are a primary defense against
infection because they ingest and destroy microorganisms (phagocytosis).
An appropriate nursing diagnosis for a client with large areas of skin excoriation
resulting from scratching an allergic rash is:
1. Risk for Impaired Skin Integrity
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Infection - ANSWER-2. Impaired Skin Integrity; The client has an actual
impairment of the skin due to the rash and the scratching so is no longer "at risk".
Because the damage is at the skin level, it is not impaired tissue integrity (option 3)
since that would involve deeper tissues. Surface excoriation is also not prone to
becoming infected.
Black wounds are treated with debridement. Which type of debridement is most
selective and least damaging?
1. Debridement with scissors
2. Debridement with wet to dry dressings
3. Mechanical debridement
