Skin Integrity & Wound Care Practice Test
Questions Chapter 36; with Answers
What physiological conditions are contraindicated for using heat as a therapy? (Select all
that apply.)
1. The first 24 hours of injury
2. Active hemorrhage
3. Noninflammatory edema
4. Localized malignant tumor - Answer All of the above; Heat causes vasodilatation and
increases blood flow to the affected area bringing oxygen, nutrients, antibodies, and
leukocytes. A possible disadvantage of heat is that it increases capillary permeability,
which allows extracellular fluid and substances to pass through the capillary walls and
may result in edema or an increase in preexisting edema.
Contraindications include: the first 24 hours of injury, active hemorrhage,
noninflammatory edema, localized malignant tumor, and skin disorder that causes
redness or blisters.
A nurse is caring for patients with a variety of wounds. Which would will most likely heal
by primary intention?
1. Cut in the skin from a kitchen knife
2. Excoriated perineal area
, 3. Abrasion of the skin
4. Pressure ulcer - Answer 1. Cut in the skin from a kitchen knife; A cut in the skin by a
sharp instrument with minimal tissue loss can heal by primary intention when the
wound edges are lightly pulled together (approximated).
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. - 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. - 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.
Questions Chapter 36; with Answers
What physiological conditions are contraindicated for using heat as a therapy? (Select all
that apply.)
1. The first 24 hours of injury
2. Active hemorrhage
3. Noninflammatory edema
4. Localized malignant tumor - Answer All of the above; Heat causes vasodilatation and
increases blood flow to the affected area bringing oxygen, nutrients, antibodies, and
leukocytes. A possible disadvantage of heat is that it increases capillary permeability,
which allows extracellular fluid and substances to pass through the capillary walls and
may result in edema or an increase in preexisting edema.
Contraindications include: the first 24 hours of injury, active hemorrhage,
noninflammatory edema, localized malignant tumor, and skin disorder that causes
redness or blisters.
A nurse is caring for patients with a variety of wounds. Which would will most likely heal
by primary intention?
1. Cut in the skin from a kitchen knife
2. Excoriated perineal area
, 3. Abrasion of the skin
4. Pressure ulcer - Answer 1. Cut in the skin from a kitchen knife; A cut in the skin by a
sharp instrument with minimal tissue loss can heal by primary intention when the
wound edges are lightly pulled together (approximated).
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. - 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. - 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.
