Exam (elaborations)
Chapter 29 Skin Integrity and Wound Care
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Chapter 29 Skin Integrity and Wound Care
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DAWITChapter 29: Skin Integrity and Wound Care
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. The nurse knows which description would be classified as a closed wound?
a. A large bruise on the side of the face
b. A surgical incision that is sutured closed
c. A puncture wound that is healing
d. An abrasion on the leg
ANS: A
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.
DIF: Applying OBJ: 29.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
2. The nurse is educating the patient about the signs and symptoms of a wound infection. Which
statement indicates a need for further education?
a. ―The wound will be red.‖
b. ―The wound will have pus.‖
c. ―The wound will be warm.‖
N R I G B.C M
d. ―The wound will need to beUtreS
atedN.‖ T O
ANS: B
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.
DIF: Applying OBJ: 29.3 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
3. The nurse identifies which type of wounds heal by tertiary intention?
a. An acute wound in which the patient has sutures placed when it happened.
b. A pressure ulcer that was treated with dressing changes and is healed.
c. An acute wound in which surgical glue was used to close the wound.
d. A wound that was left open initially and closed later with sutures.
ANS: D
NURSINGTB.COM
, DAWIT
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 ulcer.
DIF: Applying OBJ: 29.3 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
4. 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. A wound infection
b. The stitches came loose
c. Wound dehiscence
d. Wound crepitus
ANS: C
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, and crepitus is air trapped under the skin.
DIF: Analyzing OBJ: 29.3 TOP: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue IntegriN
tyURSINGTB.COM
5. 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?
a. Cover the wound with a sterile gauze pad.
b. Cover the wound with a transparent dressing.
c. Put pressure on the wound with a sterile gauze pad.
d. Cover the wound with gauze soaked with normal saline.
ANS: D
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.
DIF: Analyzing OBJ: 29.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Tissue Integrity
6. The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3
pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?
a. Wound will be completely healed in 72 hours.
b. Wound will show signs of healing within 2 weeks.
NURSINGTB.COM
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