Questions and Answers about wound
care and skin integrity
The nurse is preparing to measure the depth of a client's tunneled wound. Which of the
following implements should the nurse use to measure the depth accurately?
a. a sterile tongue blade lubricated with water soluble gel
b. an otic curette
c. a small plastic ruler
d. a sterile, flexible applicator moistened with saline - correct answer: d. a sterile, flexible
applicator moistened with saline
A client who has been confined to a hospital bed for the past 2 weeks complains of sores on the
buttocks. On examination, the nurse quickly determines that the sores are caused by unrelieved
compression of the skin that has resulted in damage to underlying tissues. This client exhibiting
signs of which of the following conditions?
a. pressure ulcers
b. jaundice
c. ecchymosis
d. ischemia - correct answer: a. pressure ulcers
The acute care nurse is caring for a client whose large surgical wound is healing by secondary
intention. The client asks, "why is my wound still open? WIll it ever heal?" which of the
following responses by the nurse is appropriate?
a. your surgeon may not have been skilled enough to close such a large wound, but it will
eventually heal
, b. as soon as the infection clears, your surgeon will staple the wound closed
c. if less scar tissue is essential, wounds are allowed to heal slowly through a process called
secondary intention
d. your wound will heal slowly as granulation tissue forms and fills the wound - correct answer:
d. your wound will heal slowly as granulation tissue forms and fills the wound
the nurse is planning to replace a client's wound dressing. The deep . wound bed is to remain
moist and requires packing. which of the following actions is appropriate?
a. Loosely pack the dampened dressing material to prevent too much pressure on the wound
bed
b. insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a
moisture impervious dressing
c. fill the wound with sterile saline gel and cover with a lrage transparent dressing
d. instill 50 mL of normal saline into the wound and loosely cover with packing material. -
correct answer: a. loosely pack dampened dressing material to prevent too much pressure on
the wound bed.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound
dressing has been changed every 12 hours. While removing the old dressing, the nurse notes
that the packing material is dry and adheres to the wound bed. Which of the following
modifications is most appropriate?
a. reduce the time interval between dressing changes
b. discontinue application of saline-moistened packing and apply hydrocolloid dressing
c. assure that the packing material is completely saturated when placed in wound
d. use less packing material - correct answer: a. reduce the time interval between dressing
changes
care and skin integrity
The nurse is preparing to measure the depth of a client's tunneled wound. Which of the
following implements should the nurse use to measure the depth accurately?
a. a sterile tongue blade lubricated with water soluble gel
b. an otic curette
c. a small plastic ruler
d. a sterile, flexible applicator moistened with saline - correct answer: d. a sterile, flexible
applicator moistened with saline
A client who has been confined to a hospital bed for the past 2 weeks complains of sores on the
buttocks. On examination, the nurse quickly determines that the sores are caused by unrelieved
compression of the skin that has resulted in damage to underlying tissues. This client exhibiting
signs of which of the following conditions?
a. pressure ulcers
b. jaundice
c. ecchymosis
d. ischemia - correct answer: a. pressure ulcers
The acute care nurse is caring for a client whose large surgical wound is healing by secondary
intention. The client asks, "why is my wound still open? WIll it ever heal?" which of the
following responses by the nurse is appropriate?
a. your surgeon may not have been skilled enough to close such a large wound, but it will
eventually heal
, b. as soon as the infection clears, your surgeon will staple the wound closed
c. if less scar tissue is essential, wounds are allowed to heal slowly through a process called
secondary intention
d. your wound will heal slowly as granulation tissue forms and fills the wound - correct answer:
d. your wound will heal slowly as granulation tissue forms and fills the wound
the nurse is planning to replace a client's wound dressing. The deep . wound bed is to remain
moist and requires packing. which of the following actions is appropriate?
a. Loosely pack the dampened dressing material to prevent too much pressure on the wound
bed
b. insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a
moisture impervious dressing
c. fill the wound with sterile saline gel and cover with a lrage transparent dressing
d. instill 50 mL of normal saline into the wound and loosely cover with packing material. -
correct answer: a. loosely pack dampened dressing material to prevent too much pressure on
the wound bed.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound
dressing has been changed every 12 hours. While removing the old dressing, the nurse notes
that the packing material is dry and adheres to the wound bed. Which of the following
modifications is most appropriate?
a. reduce the time interval between dressing changes
b. discontinue application of saline-moistened packing and apply hydrocolloid dressing
c. assure that the packing material is completely saturated when placed in wound
d. use less packing material - correct answer: a. reduce the time interval between dressing
changes
