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Chapter 48: Skin Integrity and Wound Care
Chapter 48: Skin Integrity and Wound Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. 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?
a. Decreased level of consciousness
b. Adequate dietary intake
c. Shortness of breath
d. Muscular pain
ANS: A
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect
themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or
to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear,
friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and an adequate
dietary intake are not included among the predisposing factors.
DIF:Understand (comprehension)REF:1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
http://boostgrade.info/chapter48skinintegrityandwoundcare/ 1/36
,10/15/2016 Chapter 48: Skin Integrity and Wound Care | Nursing Test Banks
TOP: Assessment MSC: Reduction of Risk Potential
2. 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?
a. Resistance
b. Pressure
c. Weight
d. Stress
ANS: B
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to
pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of
the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury
to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin
breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers.
DIF:Understand (comprehension)REF:1185-1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Planning MSC: Reduction of Risk Potential
3. Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
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 re흿ll is less than 2 seconds.
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,10/15/2016 Chapter 48: Skin Integrity and Wound Care | Nursing Test Banks
ANS: A
The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible
to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary
incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the
skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but
eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg
again is a concern and can aᖈect the integrity of the skin, but it is located on the shin, which is not a high-risk
area for skin breakdown. Pressure can in㔪uence capillary re흿ll, leading to skin breakdown, but this capillary
response is within normal limits.
DIF:Understand (comprehension)REF:1187
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Assessment MSC: Reduction of Risk Potential
4. 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?
a. Stage I pressure ulcer
b. Healing Stage II pressure ulcer
c. Healing Stage III pressure ulcer
d. Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled
with the words “healing stage” or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage
endures even as the ulcer heals. This ulcer was labeled a Stage III, and it cannot return to a previous stage such
as Stage I or II. This ulcer is healing, so it is no longer labeled a Stage III.
DIF:Understand (comprehension)REF:1187
http://boostgrade.info/chapter48skinintegrityandwoundcare/ 3/36
, 10/15/2016 Chapter 48: Skin Integrity and Wound Care | Nursing Test Banks
OBJ: Describe the pressure ulcer staging system. TOP: Implementation
MSC: Physiological Adaptation
5. 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?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis
and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with
nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be
visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with
exposed bone, tendon, or muscle.
DIF:Apply (application)REF:1187-1188
OBJ: Describe the pressure ulcer staging system. TOP: Assessment
MSC: Physiological Adaptation
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the
nurse use ᯿贄rst to assist in staging an ulcer on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
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Nursing Test Banks
One Account Get all Test Banks
Chapter 48: Skin Integrity and Wound Care
Chapter 48: Skin Integrity and Wound Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. 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?
a. Decreased level of consciousness
b. Adequate dietary intake
c. Shortness of breath
d. Muscular pain
ANS: A
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect
themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or
to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear,
friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and an adequate
dietary intake are not included among the predisposing factors.
DIF:Understand (comprehension)REF:1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
http://boostgrade.info/chapter48skinintegrityandwoundcare/ 1/36
,10/15/2016 Chapter 48: Skin Integrity and Wound Care | Nursing Test Banks
TOP: Assessment MSC: Reduction of Risk Potential
2. 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?
a. Resistance
b. Pressure
c. Weight
d. Stress
ANS: B
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to
pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of
the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury
to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin
breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers.
DIF:Understand (comprehension)REF:1185-1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Planning MSC: Reduction of Risk Potential
3. Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
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 re흿ll is less than 2 seconds.
http://boostgrade.info/chapter48skinintegrityandwoundcare/ 2/36
,10/15/2016 Chapter 48: Skin Integrity and Wound Care | Nursing Test Banks
ANS: A
The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible
to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary
incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the
skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but
eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg
again is a concern and can aᖈect the integrity of the skin, but it is located on the shin, which is not a high-risk
area for skin breakdown. Pressure can in㔪uence capillary re흿ll, leading to skin breakdown, but this capillary
response is within normal limits.
DIF:Understand (comprehension)REF:1187
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Assessment MSC: Reduction of Risk Potential
4. 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?
a. Stage I pressure ulcer
b. Healing Stage II pressure ulcer
c. Healing Stage III pressure ulcer
d. Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled
with the words “healing stage” or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage
endures even as the ulcer heals. This ulcer was labeled a Stage III, and it cannot return to a previous stage such
as Stage I or II. This ulcer is healing, so it is no longer labeled a Stage III.
DIF:Understand (comprehension)REF:1187
http://boostgrade.info/chapter48skinintegrityandwoundcare/ 3/36
, 10/15/2016 Chapter 48: Skin Integrity and Wound Care | Nursing Test Banks
OBJ: Describe the pressure ulcer staging system. TOP: Implementation
MSC: Physiological Adaptation
5. 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?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis
and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with
nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be
visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with
exposed bone, tendon, or muscle.
DIF:Apply (application)REF:1187-1188
OBJ: Describe the pressure ulcer staging system. TOP: Assessment
MSC: Physiological Adaptation
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the
nurse use ᯿贄rst to assist in staging an ulcer on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
http://boostgrade.info/chapter48skinintegrityandwoundcare/ 4/36
