A nurse is assessing a client's pressure ulcer that shows signs of infection, including
erythema, warmth, and purulent drainage. Which intervention is the nurse's priority in
managing this wound?
a) Continuation of the current wound dressing.
b) Application of a hydrocolloid dressing.
c) Initiation of broad-spectrum antibiotics.
d) Frequent wound cleaning with hydrogen peroxide. - ANSWER Answer: c) Initiation
of broad-spectrum antibiotics.
Explanation: Signs of infection in a wound, such as erythema, warmth, and purulent
drainage, indicate the presence of microorganisms that may require systemic treatment with
antibiotics to prevent systemic spread.
A client with a diabetic foot ulcer is prescribed a moist wound healing technique. Which
explanation best describes the rationale behind this approach?
a) It prevents bacteria from entering the wound.
b) It promotes the formation of a scab over the wound.
c) It facilitates faster wound closure through epithelialization.
d) It reduces inflammation and pain in the wound. - ANSWER Answer: c) It facilitates
faster wound closure through epithelialization.
1
, Explanation: Moist wound healing creates an optimal environment for cell migration,
proliferation, and angiogenesis, which promote faster wound closure through the process of
epithelialization. It also reduces the risk of scab formation and promotes better wound
healing outcomes.
A nurse is caring for a client with a suspected deep tissue injury on the sacral area. What
assessment finding is characteristic of this type of wound?
a) Blistering and serous drainage.
b) Sloughing and eschar formation.
c) Red, beefy granulation tissue.
d) Erythema and edema. - ANSWER Answer: b) Sloughing and eschar formation.
Explanation: Deep tissue injuries typically manifest as localized areas of discolored skin,
often with sloughing (dead tissue) and eschar (dry, blackened tissue) formation due to
damage to underlying tissue layers.
A client with a traumatic open wound is brought to the emergency department. The nurse
notes that the wound has irregular, jagged edges with tissue loss. This wound is best
described as:
a) A laceration.
b) An abrasion.
c) An incision.
d) An avulsion. - ANSWER Answer: a) A laceration.
Explanation: A laceration is a wound caused by a tearing of the skin and underlying tissues,
often resulting in irregular, jagged wound edges.
A client with a pressure ulcer is being treated with a collagenase enzyme ointment. What is
the primary purpose of using this ointment in wound care?
2
erythema, warmth, and purulent drainage. Which intervention is the nurse's priority in
managing this wound?
a) Continuation of the current wound dressing.
b) Application of a hydrocolloid dressing.
c) Initiation of broad-spectrum antibiotics.
d) Frequent wound cleaning with hydrogen peroxide. - ANSWER Answer: c) Initiation
of broad-spectrum antibiotics.
Explanation: Signs of infection in a wound, such as erythema, warmth, and purulent
drainage, indicate the presence of microorganisms that may require systemic treatment with
antibiotics to prevent systemic spread.
A client with a diabetic foot ulcer is prescribed a moist wound healing technique. Which
explanation best describes the rationale behind this approach?
a) It prevents bacteria from entering the wound.
b) It promotes the formation of a scab over the wound.
c) It facilitates faster wound closure through epithelialization.
d) It reduces inflammation and pain in the wound. - ANSWER Answer: c) It facilitates
faster wound closure through epithelialization.
1
, Explanation: Moist wound healing creates an optimal environment for cell migration,
proliferation, and angiogenesis, which promote faster wound closure through the process of
epithelialization. It also reduces the risk of scab formation and promotes better wound
healing outcomes.
A nurse is caring for a client with a suspected deep tissue injury on the sacral area. What
assessment finding is characteristic of this type of wound?
a) Blistering and serous drainage.
b) Sloughing and eschar formation.
c) Red, beefy granulation tissue.
d) Erythema and edema. - ANSWER Answer: b) Sloughing and eschar formation.
Explanation: Deep tissue injuries typically manifest as localized areas of discolored skin,
often with sloughing (dead tissue) and eschar (dry, blackened tissue) formation due to
damage to underlying tissue layers.
A client with a traumatic open wound is brought to the emergency department. The nurse
notes that the wound has irregular, jagged edges with tissue loss. This wound is best
described as:
a) A laceration.
b) An abrasion.
c) An incision.
d) An avulsion. - ANSWER Answer: a) A laceration.
Explanation: A laceration is a wound caused by a tearing of the skin and underlying tissues,
often resulting in irregular, jagged wound edges.
A client with a pressure ulcer is being treated with a collagenase enzyme ointment. What is
the primary purpose of using this ointment in wound care?
2
