Exam #1: Skin Integrity and Wound Care
questions with complete solution
A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline
for this procedure?
A. Once the wound is clean, dry all the areas with an absorbent cloth
B. Use clean technique to clean the wound
C. Clean the wound from the top to the bottom, and center to outside
D. Clean the wound from the bottom to the top, and outside to center -Correct Answer-Correct answer:
C
Using sterile technique, clean the wound from the top to the bottom, and from the center to the
outside.
The nurse would recognize which of the following clients as being particularly susceptible to impaired
wound healing?
A. A client who is NPO following bowel surgery
B. An obese woman with a history of type 1 diabetes
C. A client whose breast reconstruction surgery required numerous incisions
D. A man with a sedentary lifestyle and a long history of cigarette smoking -Correct Answer-Correct
answer: B
Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the
role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process
An older adult has been admitted to the hospital with dehydration, and the nurse has inserted a
peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of
dressing should the nurse apply over the client's venous access site?
A. A dressing with non-adherent coating
, B. A transparent film
C. A gauze dressing precut halfway to fit around the IV line
D. A gauze dressing pre-medicated with antibiotics -Correct Answer-Correct answer: B
Transparent film dressing are semipermeable, water proof, and adhesive, allowing for visualization of the
access site to aid assessment, as well as protecting the site from microorganisms
A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the
wound and the surgeon. Which of the following is a finding related to this condition?
A. There is an accidental separation of the wound
B. There is an accumulation of fluid in the interstitial tissue
C. The edges of the wound are lightly pulled together
D. There is redness or inflammation of an area as a result of dialtion -Correct Answer-Correct answer: A
With dehiscence, there is an accidental separation of wound edges, especially in a surgical wound.
You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better
to let my wound dry out so a scab can form?" Which of the following responses is most appropriate?
A. "Wounds heal better when a moist wound bed is maintained"
B. "Allowing a scab to form would prevent us from observing the wound for signs of infection
C. "You may be correct. I will check with your primary health care provider."
D. "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." -Correct
Answer-Correct answer: A
A moist wound surface enhances the cellular migration necessary for tissue repair and healing
Which of the following actions should the nurse perform when applying negative pressure wound
therapy?
questions with complete solution
A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline
for this procedure?
A. Once the wound is clean, dry all the areas with an absorbent cloth
B. Use clean technique to clean the wound
C. Clean the wound from the top to the bottom, and center to outside
D. Clean the wound from the bottom to the top, and outside to center -Correct Answer-Correct answer:
C
Using sterile technique, clean the wound from the top to the bottom, and from the center to the
outside.
The nurse would recognize which of the following clients as being particularly susceptible to impaired
wound healing?
A. A client who is NPO following bowel surgery
B. An obese woman with a history of type 1 diabetes
C. A client whose breast reconstruction surgery required numerous incisions
D. A man with a sedentary lifestyle and a long history of cigarette smoking -Correct Answer-Correct
answer: B
Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the
role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process
An older adult has been admitted to the hospital with dehydration, and the nurse has inserted a
peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of
dressing should the nurse apply over the client's venous access site?
A. A dressing with non-adherent coating
, B. A transparent film
C. A gauze dressing precut halfway to fit around the IV line
D. A gauze dressing pre-medicated with antibiotics -Correct Answer-Correct answer: B
Transparent film dressing are semipermeable, water proof, and adhesive, allowing for visualization of the
access site to aid assessment, as well as protecting the site from microorganisms
A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the
wound and the surgeon. Which of the following is a finding related to this condition?
A. There is an accidental separation of the wound
B. There is an accumulation of fluid in the interstitial tissue
C. The edges of the wound are lightly pulled together
D. There is redness or inflammation of an area as a result of dialtion -Correct Answer-Correct answer: A
With dehiscence, there is an accidental separation of wound edges, especially in a surgical wound.
You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better
to let my wound dry out so a scab can form?" Which of the following responses is most appropriate?
A. "Wounds heal better when a moist wound bed is maintained"
B. "Allowing a scab to form would prevent us from observing the wound for signs of infection
C. "You may be correct. I will check with your primary health care provider."
D. "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." -Correct
Answer-Correct answer: A
A moist wound surface enhances the cellular migration necessary for tissue repair and healing
Which of the following actions should the nurse perform when applying negative pressure wound
therapy?
