Chapter 48: Skin Integrity and Wound Care Questions With
Complete Solutions
A nurse is assessing a patient's wound. Which nursing
observation will indicate the wound healed by secondary
intention? Correct Answers Scarring that may be severe
A nurse is assigned most of the patients with pressure ulcers.
The nurse leaves the pressure ulcer open to air and does not
apply a dressing. To which patient did the nurse provide care?
Correct Answers A patient with a clean Stage I
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? Correct Answers Pulse oximetry assessment
A nurse is caring for a postoperative patient. Which finding will
alert the nurse to a potential wound dehiscence? Correct
Answers Report by patient that something has given way
A patient has developed a pressure ulcer. Which laboratory data
will be important for the nurse to check? Correct Answers
Albumin
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? Correct Answers Inspect the wound for
foreign bodies.
, The medical-surgical acute care patient has received a nursing
diagnosis of Impaired skin integrity. Which health care team
member will the nurse consult? Correct Answers Registered
dietitian
The nurse collects the following assessment data: right heel with
reddened area that does not blanch. Which nursing diagnosis
will the nurse assign to this patient Correct Answers Ineffective
peripheral tissue perfusion
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? Correct Answers Stage
II
The nurse is caring for a group of patients. Which patient will
the nurse see first? Correct Answers A patient with appendicitis
using a heating pad
The nurse is caring for a group of patients. Which task can the
nurse delegate to the nursing assistive personnel? Correct
Answers Applying an elastic bandage to a medical-surgical
patient
The nurse is caring for a patient after an open abdominal aortic
aneurysm repair. The nurse requests an abdominal binder and
carefully applies the binder. Which is the best explanation for
the nurse to use when teaching the patient the reason for the
binder? Correct Answers It supports the abdomen.
Complete Solutions
A nurse is assessing a patient's wound. Which nursing
observation will indicate the wound healed by secondary
intention? Correct Answers Scarring that may be severe
A nurse is assigned most of the patients with pressure ulcers.
The nurse leaves the pressure ulcer open to air and does not
apply a dressing. To which patient did the nurse provide care?
Correct Answers A patient with a clean Stage I
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? Correct Answers Pulse oximetry assessment
A nurse is caring for a postoperative patient. Which finding will
alert the nurse to a potential wound dehiscence? Correct
Answers Report by patient that something has given way
A patient has developed a pressure ulcer. Which laboratory data
will be important for the nurse to check? Correct Answers
Albumin
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? Correct Answers Inspect the wound for
foreign bodies.
, The medical-surgical acute care patient has received a nursing
diagnosis of Impaired skin integrity. Which health care team
member will the nurse consult? Correct Answers Registered
dietitian
The nurse collects the following assessment data: right heel with
reddened area that does not blanch. Which nursing diagnosis
will the nurse assign to this patient Correct Answers Ineffective
peripheral tissue perfusion
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? Correct Answers Stage
II
The nurse is caring for a group of patients. Which patient will
the nurse see first? Correct Answers A patient with appendicitis
using a heating pad
The nurse is caring for a group of patients. Which task can the
nurse delegate to the nursing assistive personnel? Correct
Answers Applying an elastic bandage to a medical-surgical
patient
The nurse is caring for a patient after an open abdominal aortic
aneurysm repair. The nurse requests an abdominal binder and
carefully applies the binder. Which is the best explanation for
the nurse to use when teaching the patient the reason for the
binder? Correct Answers It supports the abdomen.
