Practice Test Questions Chapter 36; Skin
Integrity & Wound Care questions and
answers
Your client has a Braden scale score of 17. Which is the most appropriate nursing action?
1. Assess the client again in 24h; the score is within normal limits.
2. Implement a turning schedule; the client is at increased risk for skin breakdown.
3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin
breakdown.
4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown. -
Correct Answer-2. Implement a turning schedule; the client is at increased risk for skin breakdown; A
score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate.
Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk,
for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14.
Option 4, very high risk, is assigned for those with a score of 9 or less.
Proper technique for performing a wound culture includes what?
1. Cleansing the wound prior to obtaining the specimen.
2. Swabbing for the specimen in the area with the largest collection of drainage.
3. Removing crusts or scabs with sterile forceps and then culturing the site beneath.
4. Waiting 8 hours following a dose of antibiotic to obtain the specimen. -Correct Answer-1. Cleansing
the wound prior to obtaining the specimen; Wound culture specimens should be obtained from a
cleaned area of the wound. Microbes responsible for infection are more likely to be found in viable
tissue.
Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without
causing the client the discomfort of debriding. The nurse does not generally debride a wound to obtain a
specimen. Once systemic antibiotics have been begun, the interval following a does will not significantly
affect the concentration of wound organisms.
, Which of the following items are used to perform wound care irrigation? Select all that apply.
1. Clean gloves
2. Sterile gloves
3. Refrigerated irrigating solution
4. 60-mL syringe -Correct Answer-1, 2, and 4; To irrigate a wound, the nurse uses clean gloves to remove
the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new
dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe
irrigating pressure. The irrigation fluid should be at room or body temperature-- certainly not
refrigerated.
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The
nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing indicated. -Correct Answer-3. Hydrocolloid; Hydrocolloid dressings protect shallow ulcers
and maintain an appropriate healing environment.
Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to
granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance
healing.
Which of the following are primary risk factors for pressure ulcers? Select all that apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed -Correct Answer-1, 3, & 4; Risk factors for pressure ulcers include a low-
protein diet, lengthy surgical procedures, and fever.
Integrity & Wound Care questions and
answers
Your client has a Braden scale score of 17. Which is the most appropriate nursing action?
1. Assess the client again in 24h; the score is within normal limits.
2. Implement a turning schedule; the client is at increased risk for skin breakdown.
3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin
breakdown.
4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown. -
Correct Answer-2. Implement a turning schedule; the client is at increased risk for skin breakdown; A
score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate.
Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk,
for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14.
Option 4, very high risk, is assigned for those with a score of 9 or less.
Proper technique for performing a wound culture includes what?
1. Cleansing the wound prior to obtaining the specimen.
2. Swabbing for the specimen in the area with the largest collection of drainage.
3. Removing crusts or scabs with sterile forceps and then culturing the site beneath.
4. Waiting 8 hours following a dose of antibiotic to obtain the specimen. -Correct Answer-1. Cleansing
the wound prior to obtaining the specimen; Wound culture specimens should be obtained from a
cleaned area of the wound. Microbes responsible for infection are more likely to be found in viable
tissue.
Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without
causing the client the discomfort of debriding. The nurse does not generally debride a wound to obtain a
specimen. Once systemic antibiotics have been begun, the interval following a does will not significantly
affect the concentration of wound organisms.
, Which of the following items are used to perform wound care irrigation? Select all that apply.
1. Clean gloves
2. Sterile gloves
3. Refrigerated irrigating solution
4. 60-mL syringe -Correct Answer-1, 2, and 4; To irrigate a wound, the nurse uses clean gloves to remove
the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new
dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe
irrigating pressure. The irrigation fluid should be at room or body temperature-- certainly not
refrigerated.
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The
nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing indicated. -Correct Answer-3. Hydrocolloid; Hydrocolloid dressings protect shallow ulcers
and maintain an appropriate healing environment.
Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to
granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance
healing.
Which of the following are primary risk factors for pressure ulcers? Select all that apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed -Correct Answer-1, 3, & 4; Risk factors for pressure ulcers include a low-
protein diet, lengthy surgical procedures, and fever.
