Skin Integrity And Wound Care

This question bank verified by Studydeets
All Questions
Filter by:
Question 1
Free
Multiple Choice

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?

Choose correct answer/s
A

Decreased level of consciousness

B

Adequate dietary intake

C

Shortness of breath

D

Muscular pain

Check answer
Question 2
Free
Multiple Choice

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. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer?

Choose correct answer/s
A

Resistance

B

Pressure

C

Weight

D

Stress

Check answer
Question 3
Free
Multiple Choice

Which nursing observation will indicate the patient is at risk for pressure ulcer formation?

Choose correct answer/s
A

The patient has fecal incontinence.

B

The patient ate two thirds of breakfast.

C

The patient has a raised red rash on the right shin.

D

The patient's capillary refill is less than 2 seconds.

Check answer
Question 4
Free
Multiple Choice

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 should the nurse document this ulcer in the patient's medical record?

Choose correct answer/s
A

Stage I pressure ulcer

B

Healing Stage II pressure ulcer

C

Healing Stage III pressure ulcer

D

Stage III pressure ulcer

Check answer
Question 5
Free
Multiple Choice

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

Choose correct answer/s
A

Stage I

B

Stage II

C

Stage III

D

Stage IV

Check answer
Question 6
Multiple Choice

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?

Choose correct answer/s
A
Disposable measuring tape
B
Cotton-tipped applicator
C
Sterile gloves
D
Halogen light
To unlock the question
Question 7
Multiple Choice

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?

Choose correct answer/s
A
Partial-thickness wound repair
B
Full-thickness wound repair
C
Primary intention
D
Tertiary intention
To unlock the question
Question 8
Multiple Choice

The nurse is caring for a group of patients. Which patient will the nurse see first?

Choose correct answer/s
A
A patient with a Stage IV pressure ulcer
B
A patient with a Braden Scale score of 18
C
A patient with appendicitis using a heating pad
D
A patient with an incision that is approximated
To unlock the question
Question 9
Multiple Choice

The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing?

Choose correct answer/s
A
Eschar
B
Slough
C
Granulation
D
Purulent drainage
To unlock the question
Question 10
Multiple Choice

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

Choose correct answer/s
A
Partial-thickness repair
B
Secondary intention
C
Tertiary intention
D
Primary intention
To unlock the question
Question 11
Multiple Choice

The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient?

Choose correct answer/s
A
Partial-thickness repair
B
Secondary intention
C
Tertiary intention
D
Primary intention
To unlock the question
Question 12
Multiple Choice

A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention?

Choose correct answer/s
A
Minimal loss of tissue function
B
Permanent dark redness at site
C
Minimal scar tissue
D
Scarring that may be severe
To unlock the question
Question 13
Multiple Choice

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?

Choose correct answer/s
A
The site is hurting.
B
The site is approximated.
C
The site has started to itch.
D
The site has a mass, bluish in color.
To unlock the question
Question 14
Multiple Choice

A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?

Choose correct answer/s
A
Protrusion of visceral organs through a wound opening
B
Chronic drainage of fluid through the incision site
C
Report by patient that something has given way
D
Drainage that is odorous and purulent
To unlock the question
Question 15
Multiple Choice

A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?

Choose correct answer/s
A
Vitamin E
B
Potassium
C
Albumin
D
Sodium
To unlock the question
Question 16
Multiple Choice

A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?

Choose correct answer/s
A
Muscular strength assessment
B
Pulse oximetry assessment
C
Sensation assessment
D
Sleep assessment
To unlock the question
Question 17
Multiple Choice

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?

Choose correct answer/s
A
Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results.
B
Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR).
C
Consult the wound care nurse about the change in status and the potential for infection.
D
Check with the charge nurse about the change in status and the potential for infection.
To unlock the question
Question 18
Multiple Choice

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian?

Choose correct answer/s
A
Fat
B
Protein
C
Vitamin E
D
Carbohydrate
To unlock the question
Question 19
Multiple Choice

The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?

Choose correct answer/s
A
"I am so weak and tired. I want to feel better."
B
"I am thinking I will be ready to go home early next week."
C
"I am ready for my bath and linen change right now since this is awful."
D
"I am hoping there will be something good for dinner tonight."
To unlock the question
Question 20
Multiple Choice

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, what is the next best step for the nurse to take?

Choose correct answer/s
A
Inspect the wound for foreign bodies.
B
Inspect the wound for bleeding.
C
Determine the size of the wound.
D
Determine the need for a tetanus antitoxin injection.
To unlock the question