ANS: B
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The
patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she i
1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The
nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include
a. A diet low
ANS: A
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development:
pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capill
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and
is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is
a
ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture
can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes i
3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patien
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words
"healing stage." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage I
The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer.
The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer?
a. Stage I pressure u
ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The
ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin wit
5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without
slough on the right heel of the patient. This pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV.
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in
assessment�inspection�and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light
so
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to
assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. H
ANS: C
Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do
not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, pr
7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an
example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary inten
ANS: A
A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and
re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowi
8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist,
it can resurface in _____ day(s).
a. 4
b. 2
c. 1
d. 7
ANS: C
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
Soft yellow or white tissue is characteristic of slough�a substance that needs to be removed for the wound to heal. B
9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following
in this type of repair?
a. Eschar
b. Slough
c. Granulation
d. Purulent drainage
ANS: D
A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are
approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness w
10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals
by
A.Tertiary intention.
B.Secondary intention.
C.Partial-thickness repair.
D. Primary intention.
ANS: B
A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left
open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the ch
11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.
ANS: D
A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes
filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by prim
Which nursing observation would indicate that a wound healed by secondary intention?
a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at site
d. Scarring can be severe.
ANS: D
A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth
or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it
13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the
patient was experiencing a complication of wound healing?
a. The incision site has started to itch.
b. The incision site is a
ANS: A
occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and
occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as thou
14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?
a. Complaint by patient that something has given way
b. Protrusion of visceral organs through a wound opening
c. Chronic drainage of fluid through t
ANS: A
Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is
probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin beca
15. A patient has developed a decubitus ulcer. What laboratory data would be important to gather?
a. Serum albumin
b. Creatine kinase
c. Vitamin E
d. Potassium
ANS: C
Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of
oxygenated blood is critical in wound healing. Blood flow through the pulmonary capillaries provides red blood cells for o
16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing?
a. Muscular strength assessment
b. Sleep assessment
c. Pulse oximetry assessment
d. Sensation assessment
ANS: A
The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a
life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nur
17. The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and
observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
a
ANS: C
Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing
depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A bala
18. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a
meal plan that includes increased
a. Fat.
b. Carbohydrates.
c. Protein.
d. Vitamin E.
ANS: C
The patient's psychological response to any wound is part of the nurse's assessment. Body image changes can influence
self-concept. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage,
19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is
currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states w
ANS: A
After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a
laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Addre
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the
patient is stable, the next best step is to
a. Inspect the wound for bleeding.
b. Inspect the wound for foreign bodies.
c. D
ANS: B
Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and
changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and
21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing.
Which of these actions should the nurse take first?
a. Don sterile gloves.
b. Provide analgesic medications as ordered.
c.
ANS: B
Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden
decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The hea
22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a
sudden decrease in drainage. What would be the nurse's next best step?
a. Remove the drain; a drain is no longer neede
ANS: B
A low-air-loss therapy unit is utilized for stage IV pressure ulcers and when prevention or treatment of skin breakdown is needed. If
the patient has a stage III or stage IV ulcer or a postoperative myocutaneous flap, the low-air-loss therapy unit
23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following
specialty beds would be most appropriate?
a. Standard mattress
b. Nonpowered redistribution air mattress
c. Low-air-loss
ANS: C
D�bridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of
infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move thr
24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in
caring for this patient includes
a. Monitoring of the wound.
b. Irrigation of the wound.
c. D�bridement of the woun
ANS: C
Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue.
Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing pr
25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following
orders would the nurse question?
a. Use a low-air-loss therapy unit.
b. Consult a dietitian.
c. Irrigate with hydroge
ANS: A
The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and
tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a
26. The nurse is completing an assessment of the skin's integrity, which includes
a. Pressure points.
b. All pulses.
c. Breath sounds.
d. Bowel sounds.
ANS: C
With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks
occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The t
27. The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is
rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no appare
ANS: B
Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in
turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient a
28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness
and ability to increase mobility, which intervention is most important for the nurse to complete?
a. Encourage the pati
ANS: C
After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of
Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequ
29. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses?
a. Readiness for enhanced nutrition
b. Impaired physical mobility
c. Impaired skin integrity
d. Chronic pain
ANS: A
The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue
damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, A
30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis
would the nurse assign?
a. Ineffective tissue perfusion
b. Risk for infection
c. Imbalanced nutrition: less than body req
C
The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and
food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does
31. The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection.
Which intervention would be most important for this patient?
a. Teach the family how to manage the odor associated wit
ANS: B
Assessment and a plan for the patient to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote
wound healing. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning
32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a
a. Respiratory therapist.
b. Registered dietitian.
c. Chaplain.
d. Case manager.
ANS: C
Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for
infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temp
33. The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient
is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What
Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the
treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additi
34. The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat
to treat this condition, and the nurse is providing this treatment. This patient is at risk for
a. Infection.
b. Impai
ANS: B
Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles
regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required fo
35. The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with
the caregiver. Which intervention assists in managing the expenses associated with long-term wound care?
a. Sterile te
ANS: A
Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the
skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply mo
36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin
impairment. Which initial interventions should the nurse select to decrease this risk?
a. Gentle cleaners and thorough dryi
ANS: C
When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be
individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine positi
37. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this
intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?
a. At least 3
ANS: C
When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging
the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient shoul
38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient.
What is the best method for repositioning the patient?
a. Obtain assistance and use the drawsheet to place the patient
ANS: A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows
visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot b
39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become
competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is sta
ANS: B
Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the
patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distr
40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What
should the nurse do to decrease the patient's anxiety?
a. Tell the patient to close his eyes.
b. Explain the procedure.
ANS: C
Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction
from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow
41. The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included?
a. Allowing the solution to flow from the most contaminated to the least
contaminated
Scrubbing vigorously when applying solutions to th
ANS: C
Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction
from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow
ANS: C
Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction
from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow
43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the
procedure, which intervention should the nurse implement?
a. Monitor vital signs every 15 minutes.
b. Apply brace to right k
43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the
procedure, which intervention should the nurse implement?
a. Monitor vital signs every 15 minutes.
b. Apply brace to right k
ANS: D
The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development.
44. The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission.
The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best
ANS: A, B, C, D
A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal
or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is co
1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a
multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included i
ANS: A, C, D, F
Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are
critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epi
2. The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing
wound healing? (Select all that apply.)
a. Nutrition
b. Evisceration
c. Tissue perfusion
d. Infection
e. Hemorrhage
f. Age
ANS: A, B, C, D
Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient
is able to feel heat or cold and is mobile, he can protect himself by withdrawing from the source. Knowin
3. The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in
a skin integrity assessment? (Select all that apply.)
a. "Can you easily change your position?"
b. "Do you have sensitivit
4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment?
(Select all that apply.)
a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status
4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment?
(Select all that apply.)
a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status
ANS: A, B, C, D
Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions,
edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed woun
5. The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's
responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.)
a. Inspe
ANS: B, D, E, F
Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore
skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtai
6. The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity.
Which of the following outcomes when met indicate progression toward goals? (Select all that apply.)
a. Ask whether