Ch 48 Skin Integrity and Wound Care (P&P) Questions
With Complete Solutions
(Matching) The nurse is caring for patients who need wound
dressings. Match the type of dressing the nurse applies to its
description.
a. Absorbs drainage through the use of exudate absorbers in the
dressing
b. Very soothing to the patient and do not adhere to the wound
bed
c. Barrier to external fluids/bacteria but allows wound to
"breathe"
d. Manufactured from seaweed and comes in sheet and rope
form
e. Oldest and most common absorbent dressing
1. Gauze
2. Transparent
3. Hydrocolloid
4. Hydrogel
5. Calcium alginate Correct Answers 1. ANS:E
2. ANS:C
3. ANS:A
4. ANS:B
5. ANS:D
(Multiple Response) The nurse is caring for a patient who will
have both a large abdominal bandage and an abdominal binder.
Which actions will the nurse take before applying the bandage
and binder? (Select all that apply.)
,a. Cover exposed wounds.
b. Mark the sites of all abrasions.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
e. Cleanse the area with hydrogen peroxide.
f. Assess the skin at underlying areas for circulatory impairment.
Correct Answers ANS: A, C, D, F
Before applying a bandage or a binder, the nurse has several
responsibilities. The nurse would need to inspect the skin for
abrasions, edema, and discoloration or exposed wound edges.
The nurse also is responsible for covering exposed wounds or
open abrasions with a dressing and assessing the condition of
underlying dressings and changing if soiled, as well as assessing
the skin of underlying areas that will be distal to the bandage.
This checks for signs of circulatory
impairment, so that a comparison can be made after bandages
are applied. Marking the sites of all abrasions is not necessary.
Although it is important for the skin to be clean, and even
though it may need to be cleaned with a noncytotoxic cleanser,
cleansing with hydrogen peroxide can interfere with wound
healing.
(Multiple Response) The nurse is caring for a patient with a
surgical incision that eviscerates. Which actions will
the nurse take? (Select all that apply.)
a. Place moist sterile gauze over the site.
b. Gently place the organs back.
c. Contact the surgical team.
,d. Offer a glass of water.
e. Monitor for shock. Correct Answers ANS: A, C, E
The presence of an evisceration (protrusion of visceral organs
through a wound opening) is a surgical emergency. Immediately
place damp sterile gauze over the site, contact the surgical team,
do not allow the patient anything by mouth (NPO), observe for
signs and symptoms of shock, and prepare the patient for
emergency surgery.
(Multiple Response) The nurse is caring for a patient with a
wound healing by full-thickness repair. Which phases will the
nurse monitor for in this patient? (Select all that apply.)
a. Hemostasis
b. Maturation
c. Inflammatory
d. Proliferative
e. Reproduction
f. Reestablishment of epidermal layers Correct Answers ANS:
A, B, C, D
The four phases involved in the healing process of a full-
thickness wound are hemostasis, inflammatory, proliferative,
and maturation. Three components are involved in the healing
process of a partial-thickness wound: inflammatory response,
epithelial proliferation (reproduction) and migration, and
reestablishment of the epidermal layers.
, (Multiple Response) The nurse is caring for a patient with
potential skin breakdown. Which components will the nurse
include in the skin assessment? (Select all that apply.)
a. Vision
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin Correct Answers ANS: B, C, D, E
Assessment of the skin includes both visual and tactile
inspection. Assess for hyperemia and palpate for blanching or
nonblaching. Early signs of skin damage include induration,
bogginess (less-than-normal stiffness), and increased warmth at
the injury site compared to nearby areas. Changes in temperature
can indicate changes in blood flow to that area of the skin.
Vision is not included in the skin assessment.
(Multiple Response) The nurse is completing a skin assessment
on a medical-surgical patient. Which nursing assessment
questions should be included in a skin integrity assessment?
(Select all that apply.)
a. "Can you easily change your position?"
b. "Do you have sensitivity to heat or cold?"
c. "How often do you need to use the toilet?"
d. "What medications do you take?"
e. "Is movement painful?"
f. "Have you ever fallen?" Correct Answers ANS: A, B, C, E
With Complete Solutions
(Matching) The nurse is caring for patients who need wound
dressings. Match the type of dressing the nurse applies to its
description.
a. Absorbs drainage through the use of exudate absorbers in the
dressing
b. Very soothing to the patient and do not adhere to the wound
bed
c. Barrier to external fluids/bacteria but allows wound to
"breathe"
d. Manufactured from seaweed and comes in sheet and rope
form
e. Oldest and most common absorbent dressing
1. Gauze
2. Transparent
3. Hydrocolloid
4. Hydrogel
5. Calcium alginate Correct Answers 1. ANS:E
2. ANS:C
3. ANS:A
4. ANS:B
5. ANS:D
(Multiple Response) The nurse is caring for a patient who will
have both a large abdominal bandage and an abdominal binder.
Which actions will the nurse take before applying the bandage
and binder? (Select all that apply.)
,a. Cover exposed wounds.
b. Mark the sites of all abrasions.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
e. Cleanse the area with hydrogen peroxide.
f. Assess the skin at underlying areas for circulatory impairment.
Correct Answers ANS: A, C, D, F
Before applying a bandage or a binder, the nurse has several
responsibilities. The nurse would need to inspect the skin for
abrasions, edema, and discoloration or exposed wound edges.
The nurse also is responsible for covering exposed wounds or
open abrasions with a dressing and assessing the condition of
underlying dressings and changing if soiled, as well as assessing
the skin of underlying areas that will be distal to the bandage.
This checks for signs of circulatory
impairment, so that a comparison can be made after bandages
are applied. Marking the sites of all abrasions is not necessary.
Although it is important for the skin to be clean, and even
though it may need to be cleaned with a noncytotoxic cleanser,
cleansing with hydrogen peroxide can interfere with wound
healing.
(Multiple Response) The nurse is caring for a patient with a
surgical incision that eviscerates. Which actions will
the nurse take? (Select all that apply.)
a. Place moist sterile gauze over the site.
b. Gently place the organs back.
c. Contact the surgical team.
,d. Offer a glass of water.
e. Monitor for shock. Correct Answers ANS: A, C, E
The presence of an evisceration (protrusion of visceral organs
through a wound opening) is a surgical emergency. Immediately
place damp sterile gauze over the site, contact the surgical team,
do not allow the patient anything by mouth (NPO), observe for
signs and symptoms of shock, and prepare the patient for
emergency surgery.
(Multiple Response) The nurse is caring for a patient with a
wound healing by full-thickness repair. Which phases will the
nurse monitor for in this patient? (Select all that apply.)
a. Hemostasis
b. Maturation
c. Inflammatory
d. Proliferative
e. Reproduction
f. Reestablishment of epidermal layers Correct Answers ANS:
A, B, C, D
The four phases involved in the healing process of a full-
thickness wound are hemostasis, inflammatory, proliferative,
and maturation. Three components are involved in the healing
process of a partial-thickness wound: inflammatory response,
epithelial proliferation (reproduction) and migration, and
reestablishment of the epidermal layers.
, (Multiple Response) The nurse is caring for a patient with
potential skin breakdown. Which components will the nurse
include in the skin assessment? (Select all that apply.)
a. Vision
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin Correct Answers ANS: B, C, D, E
Assessment of the skin includes both visual and tactile
inspection. Assess for hyperemia and palpate for blanching or
nonblaching. Early signs of skin damage include induration,
bogginess (less-than-normal stiffness), and increased warmth at
the injury site compared to nearby areas. Changes in temperature
can indicate changes in blood flow to that area of the skin.
Vision is not included in the skin assessment.
(Multiple Response) The nurse is completing a skin assessment
on a medical-surgical patient. Which nursing assessment
questions should be included in a skin integrity assessment?
(Select all that apply.)
a. "Can you easily change your position?"
b. "Do you have sensitivity to heat or cold?"
c. "How often do you need to use the toilet?"
d. "What medications do you take?"
e. "Is movement painful?"
f. "Have you ever fallen?" Correct Answers ANS: A, B, C, E
