Chapter 32: Skin Integrity and Wound Care
1. The nurse would recognize which client as being, particularly susceptible to impaired wound healing?
a. An obese woman with a history of type 1 diabetes
2. A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac
drain in place. Which statement indicates that the client understands?
a. “I will squeeze the chamber and apply the cap to maintain negative pressure.”
3. A nurse has applied a bandage to a client’s arm from just above the wrist to just below the elbow. What
finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.
a. Fingers with quick capillary refill
b. Warm hand
c. No finger numbness or tingling
4. The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack
indicates that nursing teaching has been effective?
a. “I will put a layer of cloth between my skin and the ice pack.”
5. The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by
primary intention?
a. A surgical incision with sutures approximated edges
6. The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching
will the nurse include?
a. “Very little scar tissue will form.”
7. A client who was injured when stepping on a rusted nail visits the health care facility. What is the most
important assessment information the nurse needs to obtain?
a. The status of the client’s tetanus immunization
8. The nurse just completed a dressing change and returned the client to a comfortable position. What
should the nurse do next?
a. Document the color, odor, amount, and type of wound drainage.
9. A client reports acute pain while negative pressure would therapy is in place. What should the nurse do
first?
a. Assess the client’s wound and vital signs
10. The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The
nurse notes pallor at the site and the client reports “it feels numb.” What is the best action by the nurse
currently?
a. Discontinue the therapy and assess the client.
11. Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing
signs of infection. When collecting this laboratory specimen, which action should the nurse take?
a. Rotate the swab several times over the wound surface to obtain an adequate specimen.
12. The wound care nurse is performing dressing changes for several clients on the unit. Which situation
reinforces the nurse’s competence in providing wound care? Select all that apply.
a. A nurse places transparent dressing over a central venous access device insertion site
b. A nurse uses aseptic techniques when changing a dressing
c. A nurse places a drainage dressing around a drain insertion site
13. An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a
peripheral intravenous line into the client’s forearm to facilitate rehydration. What type of dressing will
the nurse apply over the client’s venous access site?
a. A transparent film
1. The nurse would recognize which client as being, particularly susceptible to impaired wound healing?
a. An obese woman with a history of type 1 diabetes
2. A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac
drain in place. Which statement indicates that the client understands?
a. “I will squeeze the chamber and apply the cap to maintain negative pressure.”
3. A nurse has applied a bandage to a client’s arm from just above the wrist to just below the elbow. What
finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.
a. Fingers with quick capillary refill
b. Warm hand
c. No finger numbness or tingling
4. The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack
indicates that nursing teaching has been effective?
a. “I will put a layer of cloth between my skin and the ice pack.”
5. The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by
primary intention?
a. A surgical incision with sutures approximated edges
6. The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching
will the nurse include?
a. “Very little scar tissue will form.”
7. A client who was injured when stepping on a rusted nail visits the health care facility. What is the most
important assessment information the nurse needs to obtain?
a. The status of the client’s tetanus immunization
8. The nurse just completed a dressing change and returned the client to a comfortable position. What
should the nurse do next?
a. Document the color, odor, amount, and type of wound drainage.
9. A client reports acute pain while negative pressure would therapy is in place. What should the nurse do
first?
a. Assess the client’s wound and vital signs
10. The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The
nurse notes pallor at the site and the client reports “it feels numb.” What is the best action by the nurse
currently?
a. Discontinue the therapy and assess the client.
11. Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing
signs of infection. When collecting this laboratory specimen, which action should the nurse take?
a. Rotate the swab several times over the wound surface to obtain an adequate specimen.
12. The wound care nurse is performing dressing changes for several clients on the unit. Which situation
reinforces the nurse’s competence in providing wound care? Select all that apply.
a. A nurse places transparent dressing over a central venous access device insertion site
b. A nurse uses aseptic techniques when changing a dressing
c. A nurse places a drainage dressing around a drain insertion site
13. An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a
peripheral intravenous line into the client’s forearm to facilitate rehydration. What type of dressing will
the nurse apply over the client’s venous access site?
a. A transparent film
