NURS 309 - Chapter 48 Skin Integrity
and Wound Care
Which type of wound drainage is considered sanguineous?
Clear, watery plasma
Bright red, active bleeding
Thick and yellow, green, tan, or brown
Pale pink, watery mixture of clear and red fluid –correct answer Bright red, active
bleeding
How far beyond the wound edges would the nurse extend the sealant when framing the
periwound area of a patient?
1 to 2 cm (0.4 to 0.8 inch)
2 to 4 cm (0.8 to 1.6 inches)
2.5 to 5 cm (1 to 2 inches)
4 to 6 cm (1.6 to 2.4 inches) - correct answer 2.5 to 5 cm (1 to 2 inches)
Extending the sealant 2.5 to 5 cm (1 to 2 inches) beyond the wound edges is an
accurate nursing action when framing the periwound area with skin sealant. Extending it
,to 1 to 2 cm (0.4 to 0.8 inch) or 2 to 4 cm (0.8 to 1.6 inches) is not enough. Extending it
to 4 to 6 cm (1.6 to 2.4 inches) is more than necessary.
Which amount of fluids per kilogram per day would the nurse encourage the patient to
drink for proper wound healing?
15 to 20 mL
20 to 25 mL
25 to 30 mL
30 to 35 mL - correct answer 30 to 35 mL
Because adequate hydration is essential for cell functioning and therefore wound
healing, the nurse should encourage the patient to drink 30 to 35 mL per kilogram per
day. The amounts of 15 to 20 mL, 20 to 25 mL, and 25 to 30 mL are not enough.
Which nursing intervention would be appropriate for a patient who is at risk of skin
breakdown because of moisture? - correct answer Keep the skin dry and free of
maceration.
Which prescribe might the nurse anticipate for a patient with new-onset bowel
incontinence that is causing compromised skin integrity?
A new prescription for a diuretic
, A change in dietary prescription
The implementation of timed voiding
The implementation of physical therapy - correct answer A change in dietary
prescription
New-onset bowel incontinence is often treated with a change in diet. A nurse would
expect a new prescription for a diuretic if the patient needed increased urine output, but
this would not improve bowel incontinence. The implementation of timed voiding is more
appropriate for urinary, not bowel, incontinence. The implementation of physical therapy
would be appropriate for a patient with impaired mobility, but not bowel incontinence.
A patient's wound drainage appears thick and yellow. Which type of drainage is this
considered?
Serous
Purulent
Sanguineous
Serosanguineous - correct answer Purulent
Which dressing would be inappropriate for a patient with a clean stage 2 pressure
injury?
Silver
and Wound Care
Which type of wound drainage is considered sanguineous?
Clear, watery plasma
Bright red, active bleeding
Thick and yellow, green, tan, or brown
Pale pink, watery mixture of clear and red fluid –correct answer Bright red, active
bleeding
How far beyond the wound edges would the nurse extend the sealant when framing the
periwound area of a patient?
1 to 2 cm (0.4 to 0.8 inch)
2 to 4 cm (0.8 to 1.6 inches)
2.5 to 5 cm (1 to 2 inches)
4 to 6 cm (1.6 to 2.4 inches) - correct answer 2.5 to 5 cm (1 to 2 inches)
Extending the sealant 2.5 to 5 cm (1 to 2 inches) beyond the wound edges is an
accurate nursing action when framing the periwound area with skin sealant. Extending it
,to 1 to 2 cm (0.4 to 0.8 inch) or 2 to 4 cm (0.8 to 1.6 inches) is not enough. Extending it
to 4 to 6 cm (1.6 to 2.4 inches) is more than necessary.
Which amount of fluids per kilogram per day would the nurse encourage the patient to
drink for proper wound healing?
15 to 20 mL
20 to 25 mL
25 to 30 mL
30 to 35 mL - correct answer 30 to 35 mL
Because adequate hydration is essential for cell functioning and therefore wound
healing, the nurse should encourage the patient to drink 30 to 35 mL per kilogram per
day. The amounts of 15 to 20 mL, 20 to 25 mL, and 25 to 30 mL are not enough.
Which nursing intervention would be appropriate for a patient who is at risk of skin
breakdown because of moisture? - correct answer Keep the skin dry and free of
maceration.
Which prescribe might the nurse anticipate for a patient with new-onset bowel
incontinence that is causing compromised skin integrity?
A new prescription for a diuretic
, A change in dietary prescription
The implementation of timed voiding
The implementation of physical therapy - correct answer A change in dietary
prescription
New-onset bowel incontinence is often treated with a change in diet. A nurse would
expect a new prescription for a diuretic if the patient needed increased urine output, but
this would not improve bowel incontinence. The implementation of timed voiding is more
appropriate for urinary, not bowel, incontinence. The implementation of physical therapy
would be appropriate for a patient with impaired mobility, but not bowel incontinence.
A patient's wound drainage appears thick and yellow. Which type of drainage is this
considered?
Serous
Purulent
Sanguineous
Serosanguineous - correct answer Purulent
Which dressing would be inappropriate for a patient with a clean stage 2 pressure
injury?
Silver
