N100 Chapter 48: Skin Integrity and Wound Care Review Questions

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft)

Stage I

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

Wound after it has first been cleaned with normal saline

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which correcti

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration

Which description best fits that of serous drainage from a wound?

Clear, watery plasma

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

Ice bag

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

Using an incontinence cleaner, followed by application of a moisture-barrier ointment

Which of the following describes a hydrocolloid dressing?

A dressing that forms a gel that interacts with the wound surface

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

Reduction of stress on the abdominal incision

When is an application of a warm compress indicated? (Select all that apply.)

To relieve edema; To improve blood flow to an injured part

What is the removal of devitalized tissue from a wound called?

Debridement

Name the three important dimensions to consistently measure to determine wound healing.

Width, Length, and Depth

What does the Braden Scale evaluate?

Risk factors that place the patient at risk for skin breakdown

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?

Unstageable

Name one intervention and the rationalization to use that intervention to reduce the likelihood of a shear injury to a patient.

A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. A second intervention would be to position the patient with the head of the bed to be elevated at 30 degrees, which prevents him or h

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft)

Stage I

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

Wound after it has first been cleaned with normal saline

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which correcti

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration

Which description best fits that of serous drainage from a wound?

Clear, watery plasma

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

Ice bag

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

Using an incontinence cleaner, followed by application of a moisture-barrier ointment

Which of the following describes a hydrocolloid dressing?

A dressing that forms a gel that interacts with the wound surface

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

Reduction of stress on the abdominal incision

When is an application of a warm compress indicated? (Select all that apply.)

To relieve edema; To improve blood flow to an injured part

What is the removal of devitalized tissue from a wound called?

Debridement

Name the three important dimensions to consistently measure to determine wound healing.

Width, Length, and Depth

What does the Braden Scale evaluate?

Risk factors that place the patient at risk for skin breakdown

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?

Unstageable

Name one intervention and the rationalization to use that intervention to reduce the likelihood of a shear injury to a patient.

A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. A second intervention would be to position the patient with the head of the bed to be elevated at 30 degrees, which prevents him or h