Galen College Chapter 29: Skin Integrity & Wounds Advanced Pretest Questions And 100% Verified Answers.

Pressure ulcers form primarily as a result of? KEY WORD PRIMARY - correct answer tissue ischemia Risk Factors for Pressure Ulcers? - correct answer Immobility, Inadequate nutrition, Fecal and urinary incontinence, Decreased mental status, Diminished sensation, Excessive body heat, advanced age, poor lifting and transferring techniques, incorrect positioning, hard support surfaces, incorrect application of pressure relieving devices, friction and shearing. The nurse notes a clients kin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as what? HINT: red, small abrasion, serous (clear, watery) fluid present. - correct answer Stage II (skin is NOT intact) Ulcer comes down to dermis and epidermis The Client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the BEST intervention for the client's skin integrity? A. having the client sit up in a chair for 4-hour intervals B. Keeping the head of the bed in a high-fowlers position to increase circulation C. Keeping a written schedule of turning and positioning D. Encouraging the client to perform pelvic muscle training exercises several times day - correct answer Keeping a written schedule of turning and positioning Why? making sure pt is turning and repositioning at least every 2 hours When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? - correct answer Clean area with mild soap, dry, and add a protective moisturizer A client comes to the emergency department following an injury. The nurse implements appropriate first aid for the client when: A. removing any penetrating objects B. Elevating an affected part that is bleeding C. Vigorously cleaning areas of abrasion or laceration D. Keeping any puncture wounds from bleeding - correct answer Umbrella Answer: Apply pressure, and elevate the affected part that is bleeding A. this may be what is stabilizing patient, do not do this!!! may cause hemmorraging C. Do not do this, only delicately .. may do more harm than good D. incorrect answer The nurse is concerned that the clients midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication? Definition of dehiscence prevents wounds from busting open, splint area when coughing/deep breathing - correct answer placing a pillow over the incision site when deep breathing or coughing Following a head injury, the client has thin drainage coming from the left ear. The nurse describes drainage as what? A. Serous B. Purulent (PUS, INFECTIOUS, THICK YELLOW/GREEN) C. Cerebrospinal fluid (clear, yellow ring, need to test it) D. Serosanguineous (pale, reddish color) - correct answer SEROUS The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The GREATEST RISK exists for the client who has exposure to: A. Urine (yes risk factor but not #1) B. Purulent exudates (yes risk factor but not #1) C. Pancreatic Fluid D. Serosanguineous drainage - correct answer Pancreatic Fluids (enzymes break skin down) When cleaning a wound the nurse should? A. Wash over the wound twice & discard that swab (clean once and discard, keep sterility) B. Move from the outer region of the wound toward the center C. Start at the drainage and move outward with circular motions D. Use an antiseptic solution followed by a normal saline rinse (use normal saline FIRST then antiseptic, IF ORDERED) - correct answer Start at the drainage and move outward with circular motions least contaminated to most contaminated start in the center and move your way out The nurse is aware that application of cold is indicated for the client with? A. Menstrual cramping (add warmth, allows vasodilation ) B. An infected wound (need blood flow for oxygen, do not put HEAT or COLD (clean it out) C. A fractured ankle D. Degenerative joint disease (add warmth, to soothe patient joints) - correct answer C. Fractured Ankle RICE REST ICE (anything that's cold causes vasoconstriction, to decrease swelling) C- COMPRESSION E- Elevating The client requires support, and an abdominal binder is ordered. The nurse correctly implements the use of a binder by? - correct answer Making sure the client has adequate ventilatory capacity To reduce pressure points that may lead to pressure ulcers, the nurse should: 1. Position the client directly on the trochanter when side-lying (KEEP OFF BONY PROMINENECES) 2. Use a donut device(DECREASES BLOOD SUPPLY) for the client when sitting up (ONLY WEDGE PILLOW) 3. Elevate the head of the bed as little as possible 4. Massage over the bony prominences (NEVER, when you massage you apply pressure) - correct answer Elevate the bed as little as possible (no more than 30 degree angle) Stage I pressure ulcer - correct answer nonblanchable erythema of intact skin, one layer of skin is damaged, wounds appear red Stage II pressure ulcer - correct answer Partial-thickness superficial, skin loss, abrasion, blister, or shallow crater. SKIN IS NOT INTACT Stage III pressure ulcer 3 layers damaged - correct answer Full-thickness tissue loss that extends to subcutaneous layer (undermining & tunneling may be present) dermis, epidermis + subc damaged Stage IV pressure ulcer - correct answer Full-thickness tissue loss with exposed bone, muscle, or tendon ; all layers damaged. SKIN IS NOT INTACT. Infection, tunneling & undermining present Deep Tissue Injury - correct answer Appears dark/purple, skin is intact but discoloration will appear. skin may feel warm, firm, mushy, or cool compared to other areas. unstageable pressure ulcer - correct answer base of ulcer covered by slough and/or eschar in the wound bed. Necrotic dead tissue is shown