NUR 155 Chapter 29- Skin Integrity and Wound Care
2025 | Comprehensive Questions & Correct Answers |
100% Correct -The Ultimate Guide for Yr. (2026/2027)
Galen
Chapter 29- Skin Integrity and Wounds
Question 1 of 25
The nurse knows which description would be classified as a closed wound?
• A puncture wound that is healing
• A large bruise on the side of the face*
• An abrasion on the leg
• A surgical incision that is sutured closed
In a closed wound, as seen with bruising, the skin is still intact. An open wound is
characterized by an actual break in the skin’s surface. For example, an abrasion, a
puncture wound, and a surgical incision are types of open wounds.
Question 2 of 25
The nurse is educating the patient about the signs and symptoms of a wound infection. Which
statement indicates a need for further education?
“The wound will
have pus.”* • “The wound will need to be treated.”
• “The wound will be warm.”
• “The wound will be red.”
An infected wound shows clinical signs of infection, including redness, warmth, and
increased drainage that may or may not be purulent (contain pus), and has a bacterial
count in the tissue of at least 105/g of tissue sampled when cultured. The wound will
need to be treated for the infection.
Question 3 of 25
The nurse identifies which type of wounds heals by tertiary intention?
A wound that was left open initially and
closed later with sutures* • A pressure injury that was treated with
dressing changes and is healed
• An acute wound in which the patient has sutures placed when it happened
• An acute wound in which surgical glue was used to close the wound
, When a delay occurs between injury and closure, the wound healing is said to happen
by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which
the edges of the wound can be approximated (brought together) to heal are examples of
acute wounds. This type of wound is said to heal by primary intention. When a wound
heals by secondary intention, new tissue must fill in from the bottom and sides of the
wound until the wound bed is filled with new tissue such as a pressure injury.
Question 4 of 25
The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When
the patient complains of a “popping sensation” and a wetness in the dressing, the nurse
immediately suspects which complication?
• A wound infection
• Fistula formation
• Wound dehiscence*
• The stitches came loose
Wound dehiscence, which usually occurs in connection with surgical incisions, is the
partial or complete separation of the tissue layers during the healing process. This is an
emergency situation. Stitches can come loose, but there is no popping sensation.
Wound infections are characterized by redness, warmth, and drainage. A fistula is an
abnormal connection between two internal organs or between an internal organ and,
through the skin, the outside of the body.
Question 5 of 25
The nurse is caring for a postoperative patient who has had abdominal surgery and whose
wound has completely eviscerated when the nurse walks into the room. In addition to notifying
the surgeon, what should the nurse do?
• Cover the wound with a transparent dressing.
• Put pressure on the wound with a sterile gauze pad.
• Cover the wound with a sterile gauze pad.
• Cover the wound with gauze soaked with normal saline.*
If dehiscence or evisceration occurs, cover the wound with gauze moistened with a
sterile normal saline and notify the surgeon immediately. Putting pressure on the wound
could cause further complications. Transparent films are used for autolytic debridement.
A gauze pad will allow the wound to become dry and cause further complications.
Question 6 of 25
The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3
pressure injury who has a nursing diagnosis of impaired skin integrity?
• Patient will ambulate twice a day.
2025 | Comprehensive Questions & Correct Answers |
100% Correct -The Ultimate Guide for Yr. (2026/2027)
Galen
Chapter 29- Skin Integrity and Wounds
Question 1 of 25
The nurse knows which description would be classified as a closed wound?
• A puncture wound that is healing
• A large bruise on the side of the face*
• An abrasion on the leg
• A surgical incision that is sutured closed
In a closed wound, as seen with bruising, the skin is still intact. An open wound is
characterized by an actual break in the skin’s surface. For example, an abrasion, a
puncture wound, and a surgical incision are types of open wounds.
Question 2 of 25
The nurse is educating the patient about the signs and symptoms of a wound infection. Which
statement indicates a need for further education?
“The wound will
have pus.”* • “The wound will need to be treated.”
• “The wound will be warm.”
• “The wound will be red.”
An infected wound shows clinical signs of infection, including redness, warmth, and
increased drainage that may or may not be purulent (contain pus), and has a bacterial
count in the tissue of at least 105/g of tissue sampled when cultured. The wound will
need to be treated for the infection.
Question 3 of 25
The nurse identifies which type of wounds heals by tertiary intention?
A wound that was left open initially and
closed later with sutures* • A pressure injury that was treated with
dressing changes and is healed
• An acute wound in which the patient has sutures placed when it happened
• An acute wound in which surgical glue was used to close the wound
, When a delay occurs between injury and closure, the wound healing is said to happen
by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which
the edges of the wound can be approximated (brought together) to heal are examples of
acute wounds. This type of wound is said to heal by primary intention. When a wound
heals by secondary intention, new tissue must fill in from the bottom and sides of the
wound until the wound bed is filled with new tissue such as a pressure injury.
Question 4 of 25
The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When
the patient complains of a “popping sensation” and a wetness in the dressing, the nurse
immediately suspects which complication?
• A wound infection
• Fistula formation
• Wound dehiscence*
• The stitches came loose
Wound dehiscence, which usually occurs in connection with surgical incisions, is the
partial or complete separation of the tissue layers during the healing process. This is an
emergency situation. Stitches can come loose, but there is no popping sensation.
Wound infections are characterized by redness, warmth, and drainage. A fistula is an
abnormal connection between two internal organs or between an internal organ and,
through the skin, the outside of the body.
Question 5 of 25
The nurse is caring for a postoperative patient who has had abdominal surgery and whose
wound has completely eviscerated when the nurse walks into the room. In addition to notifying
the surgeon, what should the nurse do?
• Cover the wound with a transparent dressing.
• Put pressure on the wound with a sterile gauze pad.
• Cover the wound with a sterile gauze pad.
• Cover the wound with gauze soaked with normal saline.*
If dehiscence or evisceration occurs, cover the wound with gauze moistened with a
sterile normal saline and notify the surgeon immediately. Putting pressure on the wound
could cause further complications. Transparent films are used for autolytic debridement.
A gauze pad will allow the wound to become dry and cause further complications.
Question 6 of 25
The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3
pressure injury who has a nursing diagnosis of impaired skin integrity?
• Patient will ambulate twice a day.
