Nursing fundamentals-wound care Exam Quiz and Answers 100% Solved 2025

Nursing fundamentals-wound care Exam Quiz and Answers 100% Solved 2025 functions of the skin - Answer- 1. protection 2. sensation -pain,touch,temp,pressure 3. thermoregulation &excretion- regulates body temp. 4. metabolism-vitamin D synthesis with prescience of sunlight 5. body image what compromises skin function and wound healing? - Answer- tissue perfusion oxygenation nutritional status(protein) aging(thinning skin) disease (cardiovascular, respiratory,diabetes,immunocompromised) medication (steroids) fever sun hydration status obesity anatomy of the skin - Answer- epidermis 0.005mm-1.5mm dermis 0.3mm-3mm subcutaneous fat types of wound healing-primary intention - Answer- -surgical closure -fastest type of wound closure -edges approximated -lowers risk of infection -involves little tissue loss/defect -closes w/out formation of granulation tissue -heals w/ minimal scarring types of wound healing-secondary intention - Answer- -chronic wounds (pressure ulcers, surgical wounds left open and healed by production of scar tissue) -edges not approximated -greater tissue loss - formation of granulation tissue from the base and edges of wound toward the surface. - higher risk of infection -epithelium eventually grows over granulation types of wound healing-tertiary intention - Answer- -delayed surgical closure - surgical wounds left open for 3-5 days - provides time to decrease edema or infection -closed with sutures, staples, or adhesive - heals with more scar tissue than primary phases of wound healing-#1 inflammatory (1-6 days) - Answer- -reactive - classic signs:heat, redness, pain, swelling, fever - purpose: to neutralize and destroy toxic agents at site of injury to restore homeostasis(phagocytosis) - consists of platelets and leukocytes (neutrophils and monocytes) phases of wound healing-#2 proliferative (4-24 days) - Answer- -regenerative - purpose: formation of granulation tissue and epithelialization (duration is dependent on wound size) - granulation tissue forms as a result of migrating fibroblasts to the area of injury and formation of new capillaries -epithelial cells at the wound margin migrate to clot and seal wounds -healing ridge should be seen at day 5-7 ; if not wound is at risk for dehiscence phases of wound healing-#3 maturation (21 + days) - Answer- - remodeling - purpose-mature granulation tissue - reorganization of new collagen fibers (formed in proliferative phase by fibroblasts) to form lattice type structure that continues to increase tensile strength. - strength is up to 70% in four weeks-tissue will only ever be at 80% of original strength - protein deficiency-impaired/inhibited remodeling assessment and documentation - Answer- 1. information collection-head to toe skin assessment and pt history 2. type/classification of wound 3. wound etiology 4. location, measurement, appearance, shape, pain 5. overall physical health-risk assessment and identify causative factors and comorbidities 6. nutritional and hydration status 7. psychosocial health 8. vascular status 9. environmental and caregiver issues wound location - Answer- -should be precisely identified -use directional terms and correct anatomical location buttocks:sacral,coccyx,ischium, trochanter,gluteal cleft abdomen: LLQ,LUQ, suprapubic etc.. wound base (muscle,tendon,bone) - Answer- -muscle - pink to dark red, firm, highly vascular - tendon - covering over muscles shiny white, thick to thin, contains muscle or muscle groups bone - describe if seen or palpable wound base (eschar, slough) - Answer- -eschar- black, brown necrotic tissue, thick consistency; can be hard or soft -slough - yellow,tan, gray, white, green devitalized tissue; thin, stringy consistency tunneling - Answer- - pathway that can extend in any direction from the wound and results in dead space with potential for abscess formation - also called sinus tract - use clockwise face documentation with pt head as 12o'clock -ex. tunneling at 9o'clock, measuring 3cm long, tract size 1.5cm undermining - Answer- - area of tissue destruction underlying intact skin along the wound margins - space between the surrounding skin and the wound bed -involves significant portion of wound edge - may extend circumferentially around wound -subcutaneous fat necrosis -usually indicates aerobic and anaerobic bacteria wound shape - Answer- irregular round oval crater like punched out wound edges - Answer- attached/unattached fibrotic/firm rolled/curled under/epibole periwound skin - 4cm circumferentially - Answer- -edema (pitting?) -induration -erythema -maceration -rash - absence of hair - hemosiderin staining -intact? -presence of foreign bodies?-sutures,staples,drains,environmental debris -dark skin may appear purple or gray or deeper color of baseline pigmentation -dry wound exudate - Answer- odor - clean or irrigate wound with wound cleanser or ns; note the presence or absence of odor drainage- amount, color, type wound exudate -type-sanguineous/bloody - Answer- red; thin, watery; disruption of blood vessels wound exudate-type-serosanguineous - Answer- light red to pink; thin, watery; normal during inflammatory and proliferative phases of healing wound exudate-type-serous - Answer- clear to straw colored;thin,watery;normal during inflammatory and proliferative phases of healing wound exudate-type-seropurulent - Answer- cloudy, yellow to tan; thin, watery; may be first sign of impending wound infection wound exudate-type-purulent - Answer- yellow,tan, or brown; thick, opaque; signals wound infection