2. Skin Integrity Certification Review Exam Questions And Answers| Download.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a) Document the findings and continue to monitor the patient. b) Administer antipyretics, as ordered. c) Increase the frequency of assessment to every hour and notify the patient's primary care provider. d) Increase the frequency of wound care and contact the primary care provider for an antibiotic order. - correct answer a) Document the findings and continue to monitor the patient. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise. A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a) Serous drainage is composed of the clear portion of the blood and serous membranes. b) Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c) Bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d) Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e) Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f) Serosanguineous drainage can be dark yellow or green depending on the causative organism. - correct answer a, b, c, d Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged. A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a) Notify the physician immediately of the situation. b) Cover the exposed tissue with sterile towels moistened with sterile NSS. c) Place the patient in the low Fowler's position. - correct answer c, b, a Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position, cover the exposed tissue with sterile towels moistened with sterile NSS, and notify the physician immediately of the situation. A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a) Pain b) Impaired Skin Integrity c) Disturbed Body Image d) Disturbed Thought Processes - correct answer c) Disturbed Body Image Wounds cause emotional as well as physical stress. A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a) Using sterile dressing supplies b) Suggesting dietary supplements c) Applying antibiotic ointment d) Performing careful hand hygiene - correct answer d) Performing careful hand hygiene Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important. A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a) Hemostasis occurs immediately after the initial injury. b) A liquid called exudate is formed during the proliferation phase. c) White blood cells move to the wound in the inflammatory phase. d) Granulation tissue forms in the inflammatory phase. e) During the inflammatory phase, the patient has generalized body response. f) A scar forms during the proliferation phase. - correct answer a, c, e Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking out of plasma and blood components into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar. The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a) Enhanced healing due to the presence of sugars and proteins b) Delayed healing due to dead tissue present in the wound c) Decreased effectiveness of antibiotics against the bacteria d) Impaired skin integrity due to overhydration of the cells of the wound e) Delayed healing due to cells dehydrating and dying f) Decreased effectiveness of the patient's normal immune process - correct answer c, f Wound biofilms are the result of wound bacteria growing in clumps, imbedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Beitz, 2012). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment. The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a) Use standard precautions or transmission-based precautions when indicated. b) Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c) Clean the wound in full or half circles beginning on the outside and working toward the center. d) Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e) Clean to at least one inch beyond the end of the new dressing if one is being applied. f) Clean to at least three inches beyond the wound if a new dressing is not being applied. - correct answer a, b, e The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least one inch beyond the end of the new dressing, and (6) clean to at least two inches beyond the wound margins if a dressing is not being applied. A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply. a) The patient takes time to think about her responses to questions. b) The patient's age of 86 years. c) Patient reports inability to control urine. d) A scheduled hip arthroplasty e) Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL). f) Patient reports increased pain in right hip when repositioning in bed or chair. - correct answer b, c, d, f Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure ulcer development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure ulcer development. Apathy, confusion, and/or altered mental status are risk factors for pressure ulcer development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure ulcer development. A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?