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Ch. 29 - Wound Care & Skin Integrity Exam Questions and Answers
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Ch. 29 - Wound Care & Skin Integrity Exam Questions and Answers
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Ch. 29 - Wound Care & SkinIntegrity Exam Questions and
Answers
A nurse is managing wound care for a patient with a stage III pressure ulcer
on the elbow. The nurse cleans the area and removes all the dead, nonviable
tissue from the wound. Which term is used to describe this process?
Irrigation
Debridement
Hemostasis
Cleansing - -Debridement
Rationale
Removal of nonviable necrotic tissue from the wound is called debridement,
which can be accomplished chemically, mechanically, autolytically, or
surgically. Debridement rids the wound of dead tissues that are ideal for
bacterial growth and minimizes the risk of infection. Irrigation involves
cleaning the wound with a cleaning solution under pressure to remove
bacteria and exudates from the wound bed and maintain moisture.
Hemostasis is the control of bleeding from a wound. Cleansing is not used to
describe the process of removal of dead tissue from the wound.
-Which factor increases the risk of wound infection?
Absence of necrotic tissue
Absence of foreign body in the wound
Reduced local tissue defenses
Adequate blood supply - -Reduced local tissue defenses
Rationale
Reduced local defenses may prevent any counter activity against the
microorganisms infecting the wound. Absence of necrotic tissue decreases
the risk of infection by improving the blood supply. A foreign body in the
wound increases the risk of infection by acting as a port of entry for the
microorganisms. Adequate blood supply is important for preventing infection.
, -A long-term care facility encourages nurses to assess patients at risk of
developing pressure ulcers based on six subscales: moisture, sensory
perception, activity, mobility, nutrition, and friction or shear force. Which tool
is the facility using for risk assessment of pressure ulcer development?
GNASC tool
Braden Scale
Bates-Jensen tool
WOCN scale - -Braden Scale
Rationale
The Braden Scale is a widely used tool for risk assessment of pressure ulcer
development and is composed of six subscales, which are moisture, sensory
perception, activity, mobility, nutrition, and friction or shear. The GNASC tool
is used to assess stage I pressure ulcers in patients with dark skin tone. The
Bates-Jensen tool is used to assess the wound status. WOCN or the Wound,
Ostomy, and Continence Nurses Society does not provide any measurement
or assessment tools.
-The primary health care provider instructs the nurse to apply a bandage on
a patient's injured leg. The nurse finds that the patient is anxious. Which
nursing action would be taken first in this situation?
Explain the procedure to the patient.
Notify the primary health care provider.
Apply the bandage to the patient immediately.
Elevate the patient's leg for 15 minutes before applying the bandage. - -
Explain the procedure to the patient.
Rationale
Sometimes the patient feels uncomfortable and becomes anxious when a
bandage is placed over wound dressings to provide support. In this situation,
the nurse should explain the procedure to the patient. This relieves the
patient's anxiety and facilitates the patient's cooperation. Anxiety is a
normal reaction to a medical procedure. Nurses are accustomed to
managing patient anxiety associated with bandaging, and the health care
provider does not need to be notified. The patient is anxious; therefore the
nurse should not apply the bandage to the patient immediately because the
patient may feel uncomfortable. Elevating the leg 15 minutes before
, applying a bandage is a secondary intervention. It promotes venous return
and reduces edema. This would be advisable but does not reduce anxiety.
-The nurse is caring for a bedridden patient. During the physical
examination, the nurse observes that the patient has intact, nonblistered
skin with nonblanchable erythema at the sacral area. Which stage of
pressure injury does the nurse suspect in the patient?
I
II
III
IV - -I
Rationale
A pressure ulcer is a localized injury caused by complete or partial
obstruction of the blood flow to the soft tissue at the site of the injury. Intact,
nonblistered skin with nonblanchable erythema is a manifestation of a stage
I pressure ulcer. Symptoms of a stage II pressure ulcer include shallow and
superficial pink wounds and intact or ruptured blisters. A full-thickness
wound and the presence of undermining or tunneling in the wound are
symptoms of a stage III pressure ulcer. A deep wound and infection of the
bone are symptoms of a stage IV pressure ulcer.
-Which nursing intervention would prevent venous stasis in a patient who
has a lower limb wound?
Raising the bed height to a higher level
Elevating the patient's leg for 30 minutes
Ensuring the bandage is clean and rolled
Exposing the wound for some time before wrapping it - -Elevating the
patient's leg for 30 minutes
Rationale
Elevation of the leg allows gravity to assist in venous drainage from the
peripheral leg veins. Raising the patient's bed may prevent discomfort for
the nurse but does not promote venous return. The use of a clean and rolled
bandage helps decrease the spread of microorganisms, and the rolled
bandage facilitates easy application. Exposing the wound helps position the
wounded limb properly before applying the bandage.
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