Skin Integrity and Wound Care Questions with correct Answers

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure? A. Once the wound is clean, dry all the areas with an absorbent cloth B. Use clean technique to clean the wound C. Clean the wound from the top to the bottom, and center to outside D. Clean the wound from the bottom to the top, and outside to center - ANS-Correct answer: C Using sterile technique, clean the wound from the top to the bottom, and from the center to the outside. The nurse would recognize which of the following clients as being particularly susceptible to impaired wound healing? A. A client who is NPO following bowel surgery B. An obese woman with a history of type 1 diabetes C. A client whose breast reconstruction surgery required numerous incisions D. A man with a sedentary lifestyle and a long history of cigarette smoking - ANS-Correct answer: B Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process An older adult has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? A. A dressing with non-adherent coating B. A transparent film C. A gauze dressing precut halfway to fit around the IV line D. A gauze dressing pre-medicated with antibiotics - ANS-Correct answer: B Transparent film dressing are semipermeable, water proof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and the surgeon. Which of the following is a finding related to this condition? A. There is an accidental separation of the wound B. There is an accumulation of fluid in the interstitial tissue C. The edges of the wound are lightly pulled together D. There is redness or inflammation of an area as a result of dialtion - ANS-Correct answer: A With dehiscence, there is an accidental separation of wound edges, especially in a surgical wound. You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate? A. "Wounds heal better when a moist wound bed is maintained" B. "Allowing a scab to form would prevent us from observing the wound for signs of infection C. "You may be correct. I will check with your primary health care provider." D. "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." - ANS-Correct answer: A A moist wound surface enhances the cellular migration necessary for tissue repair and healing Which of the following actions should the nurse perform when applying negative pressure wound therapy? A. Test the seal of the completed dressing by briefly attaching it to wall suction B. Cut foam to the shape of the wound and place it in the wound C. Increase the negative pressure setting until drainage is brisk D. Irrigate the wound thoroughly using normal saline and clean technique - ANS-Correct answer: B When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound bed. Irrigation requires sterile, not clean, clean technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather then increased until drainage is visible The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my would still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate? A. "As soon as the infection clears, your surgeon will staple the wound closed" B. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention" C. "Your wound will heal slowly as granulation tissue forms and fills the wound" D. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal" - ANS-Correct answer: C There is no indication of infection. Large wounds with extensive tissue loss may not be able to be closed by primary intention What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? A. Hydrocolloid dressings B. Alginates C. Transparent films D. Hydrogels - ANS-Correct answer: A Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for 3-7 days, this resulting in less interference with healing A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? A. A child's skin becomes less resistant to injury and infection as the child grows B. An individual's skin changes little over the life span C. An infant's skin and mucous membranes are easily injured and at risk for infection D. In children younger than 2 years, the skin is thicker and stronger than in adults - ANS-Correct answer: C 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 adults. The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to client's stat of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? A. Necrosis B. Evisceration C. Desiccation D. Maceration - ANS-Correct answer: C Desiccation is localized wound dehydration Maceration is localized over-hydrated or excessive moisture What observation should the nurse note about a client's open wound if the wound is healing by the third-intention? A. Wound edges are close to each other but require closure material B. Wound edges are directly next to each other C. Wound edges are widely separated leading to complex reparative process D. Wound edges are widely separated and brought together with closure material - ANS-Correct answer: D With third-intention healing, the wound edges are widely separated and are later brought together with some type of closure material A nurse is measuring the wound of a stab victim by moistening a sterile flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? A. Tunneling B. Direction C. Size D. Depth - ANS-Correct answer: D When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. A. Clean from the outside of the wound to the center B. Use a sterile applicator to apply any ointment that is ordered C. Clean the wound from top to bottom D. Avoid touching the wound bed, whether with gloves or forceps E. Use a new gauze for each wipe of the wound - ANS-Correct answer: B, C, D, E 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. An otic curette B. A sterile, flexible applicator moistened with saline C. A sterile tongue blade lubricated with water soluble gel D. A small plastic ruler - ANS-Correct answer: B A sterile, flexible applicator is the safest implement to use. A physician order the application of a warm, sterile compress to reduce edema in a client's wound. Which of the following is a recommended step in this procedure? A. Keep the dressing in place for the prescribed amount of time or up to 30 min B. Apply pressure to the compress to mold it around the wound site C. Cover the site with a three layers of gauze and with a clean, dry bath towel D. Place an aqua-thermia or heating device directly on the dressing - ANS-Correct answer: A After the prescribed time for the treatment, the external heating device should be removed A client who has a bacterial infection develops an abscess that need to be drained. What drainage system would most likely be used in this situation? A. Penrose drain B. Jackson-Pratt drain C. Hemovac drain D. Wound pouching - ANS-Correct answer: A Penrose drains are commonly used after a surgical procedure or for drainage of an abscess