Yoost Chapter 29: Skin Integrity and Wound Care practice questions with correct answers
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Course
Skin Integrity and Wound Care
Institution
Skin Integrity And Wound Care
Yoost Chapter 29: Skin Integrity and Wound Care practice questions with correct answers
On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that, when pressed lightly, does not blanch. What does this assessment finding indicate to the nurse?
a. The...
Yoost Chapter 29: Skin Integrity and
Wound Care practice questions with
correct answers
On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that,
when pressed lightly, does not blanch. What does this assessment finding indicate to the nurse?
a. The presence of an infection in the area
b. The presence of a stage I pressure ulcer
c. An allergic reaction to the sheets
d. The need to apply a cold compress to reduce inflammation -Correct Answer-b
(Nonblanchable erythema over an area of pressure defines a stage I pressure ulcer. An infection is likely
to occur in an open sore and would be associated with signs of redness, warmth, and green or yellow
exudate. An allergic reaction would manifest as a rash or itchy area. Cold compresses would cause
vasoconstriction and further damage because the blood flow has already been restricted.)
Four days after abdominal surgery, the patient is getting out of bed and feels something "pop" in his
abdominal wound. An increase in amount of drainage from the wound is seen, and further examination
shows that the sutured incision is now partially open, with tissue protruding from the wound. What is
the nurse's next action?
a. Apply Steri-Strips to close the wound edges.
b. Cover the wound with saline-moistened gauze, and notify the physician.
c. Assure the patient that this is common, and document the findings.
d. Apply a binder to pull the wound edges together and provide support to the edges. -Correct Answer-b
(This is likely to be an evisceration of the surgical wound and, as such, may require surgical intervention.
The normal saline keeps the wound and tissue moist until they can be evaluated by the physician. Steri-
Strips can be used to reinforce a closed wound when sutures or staples are removed but are not used to
try to close a wound that has opened and has tissue protruding through. False reassurance should not be
given. A binder is used to support a closed incision and should not be applied to a wound with tissue
protruding.)
Which features are characteristic of a closed drainage system such as a Jackson-Pratt (JP) drain? (Select
all that apply.)
, a. Works by gravity
b. Provides for early discharge
c. Usually is inserted in surgery
d. Reduces the amount of antibiotics required
e. Allows for accurate measurement of wound drainage
f. Allows bacteria to migrate up the drain from the surrounding dressing -Correct Answer-c, e
(JP drains usually are inserted at surgery. Unlike an open drainage device such as the Penrose drain, a JP
drain does not allow drainage to soak into the surrounding dressing and allows for an accurate
measurement of the drainage. JP drains work by suction, not gravity. Discharge and antibiotic use are not
dependent on the type of drain. Bacteria migration from the dressing will not occur because a JP drain is
a closed system.)
Which intervention should be initiated by the nurse caring for a patient with urinary or fecal
incontinence?
a. Using a heat lamp to dry the skin
b. Changing the adult brief every 8 hours
c. Cleansing frequently with hot water and a strong soap
d. Using an incontinence cleanser and a moisture barrier ointment -Correct Answer-d
(Skin care for the incontinent patient should include cleansing as needed using a mild, pH-neutral soap
and warm (not hot) water, to prevent the stripping of oils from the skin and reduction in the skin's
normally acidic pH. Application of a moisture barrier ointment protects the skin from the moisture and
irritation that can result from urinary or fecal incontinence. An adult brief should be changed with every
incontinence episode. A heat lamp could further damage delicate skin.)
Based on knowledge of areas at greatest risk for development of a pressure ulcer in the bedridden
patient, the nurse identifies which position to minimize this risk?
a. 30-degree side-lying
b. Sitting with the head of the bed elevated 75 degrees
c. 90-degree side-lying
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