Ch. 32: Skin Integrity and wound care
The nurse is taking care of a client who asks about wound dehiscence. It is the second
postoperative day. Which response by the nurse is most accurate? - correct answer
"Dehiscence is when a wound has partial or total separation of the wound layers."
When performing a dressing change, the home care nurse notes that the base of the client's leg
wound is red and bleeds easily. What is the appropriate action by the nurse? - correct answer
Document the findings.
Which is not considered a skin appendage? - correct answer Connective tissue
The nurse is teaching a client about healing of a minor surgical wound by first intention. What
teaching will the nurse include? - correct answer "Very little scar tissue will form."
The nurse is teaching a client about wound care at home following a cesarean birth of her baby.
Which client statement requires further nursing teaching? - correct answer "Reinforced
adhesive skin closures will hold my wound together until it heals."
A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the
mother: - correct answer to apply sunscreen when exposed to ultraviolet rays.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is
performed correctly? - correct answer The nurse keeps the pad in place for 20 to 30 minutes,
assessing it regularly.
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal
by primary intention? - correct answer a surgical incision with sutured approximated edges
The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer.
Which teaching about a Jackson-Pratt drain will the nurse include? - correct answer "It
provides a way to remove drainage and blood from the surgical wound."
A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden
client several months ago. Which guideline should inform the nurse's practice? - correct
answer It is appropriate to use clean technique during this procedure.
The nurse would recognize which client as being particularly susceptible to impaired wound
healing? - correct answer an obese woman with a history of type 1 diabetes
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's
coccyx wound. What is the primary goal of this action? - correct answer removing dead or
infected tissue to promote wound healing
A nurse is caring for a client with dehydration at the health care facility. The client is receiving
glucose intravenously. What type of dressing should the nurse use to cover the IV insertion
site? - correct answer transparent
, Ch. 32: Skin Integrity and wound care
A postoperative client is being transferred from the bed to a gurney and states, "I feel like
something has just given away." What should the nurse assess in the client? - correct answer
Dehiscence of the wound
The nurse is changing the dressing of a client with a gunshot wound. What nursing action would
the nurse provide? - correct answer The nurse selects a dressing that absorbs exudate, if it is
present, but still maintains a moist environment.
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is
recommended for this procedure? - correct answer Clean the wound from the top to the
bottom and from the center to outside.
A nurse removing sutures from a client's traumatic wound notices that the sutures are
encrusted with blood and difficult to remove. What would be the nurse's most appropriate
action? - correct answer Moisten sterile gauze with sterile saline to gently loosen crusts before
removing sutures.
A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the
major purpose of the roller bandage? - correct answer Supports the area around the wound
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice
pack indicates that nursing teaching has been effective? - correct answer "I will put a layer of
cloth between my skin and the ice pack."
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement
describes the common skin characteristics in a child? - correct answer An infant's skin and
mucous membranes are easily injured and at risk for infection.
The acute care nurse is caring for a client whose large surgical wound is healing by secondary
intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by
the nurse is most appropriate? - correct answer "Your wound will heal slowly as granulation
tissue forms and fills the wound."
A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound
dehiscence. Which type of wound repair would the nurse expect with this wound? - correct
answer secondary intention
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary
care provider placed the client on bed rest. Which action should the nurse perform to prevent a
pressure injury? - correct answer use pillows to maintain a side-lying position as needed
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-
approximated edges and no signs of infection. How will the nurse document this assessment
finding? - correct answer incision
The nurse is taking care of a client who asks about wound dehiscence. It is the second
postoperative day. Which response by the nurse is most accurate? - correct answer
"Dehiscence is when a wound has partial or total separation of the wound layers."
When performing a dressing change, the home care nurse notes that the base of the client's leg
wound is red and bleeds easily. What is the appropriate action by the nurse? - correct answer
Document the findings.
Which is not considered a skin appendage? - correct answer Connective tissue
The nurse is teaching a client about healing of a minor surgical wound by first intention. What
teaching will the nurse include? - correct answer "Very little scar tissue will form."
The nurse is teaching a client about wound care at home following a cesarean birth of her baby.
Which client statement requires further nursing teaching? - correct answer "Reinforced
adhesive skin closures will hold my wound together until it heals."
A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the
mother: - correct answer to apply sunscreen when exposed to ultraviolet rays.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is
performed correctly? - correct answer The nurse keeps the pad in place for 20 to 30 minutes,
assessing it regularly.
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal
by primary intention? - correct answer a surgical incision with sutured approximated edges
The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer.
Which teaching about a Jackson-Pratt drain will the nurse include? - correct answer "It
provides a way to remove drainage and blood from the surgical wound."
A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden
client several months ago. Which guideline should inform the nurse's practice? - correct
answer It is appropriate to use clean technique during this procedure.
The nurse would recognize which client as being particularly susceptible to impaired wound
healing? - correct answer an obese woman with a history of type 1 diabetes
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's
coccyx wound. What is the primary goal of this action? - correct answer removing dead or
infected tissue to promote wound healing
A nurse is caring for a client with dehydration at the health care facility. The client is receiving
glucose intravenously. What type of dressing should the nurse use to cover the IV insertion
site? - correct answer transparent
, Ch. 32: Skin Integrity and wound care
A postoperative client is being transferred from the bed to a gurney and states, "I feel like
something has just given away." What should the nurse assess in the client? - correct answer
Dehiscence of the wound
The nurse is changing the dressing of a client with a gunshot wound. What nursing action would
the nurse provide? - correct answer The nurse selects a dressing that absorbs exudate, if it is
present, but still maintains a moist environment.
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is
recommended for this procedure? - correct answer Clean the wound from the top to the
bottom and from the center to outside.
A nurse removing sutures from a client's traumatic wound notices that the sutures are
encrusted with blood and difficult to remove. What would be the nurse's most appropriate
action? - correct answer Moisten sterile gauze with sterile saline to gently loosen crusts before
removing sutures.
A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the
major purpose of the roller bandage? - correct answer Supports the area around the wound
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice
pack indicates that nursing teaching has been effective? - correct answer "I will put a layer of
cloth between my skin and the ice pack."
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement
describes the common skin characteristics in a child? - correct answer An infant's skin and
mucous membranes are easily injured and at risk for infection.
The acute care nurse is caring for a client whose large surgical wound is healing by secondary
intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by
the nurse is most appropriate? - correct answer "Your wound will heal slowly as granulation
tissue forms and fills the wound."
A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound
dehiscence. Which type of wound repair would the nurse expect with this wound? - correct
answer secondary intention
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary
care provider placed the client on bed rest. Which action should the nurse perform to prevent a
pressure injury? - correct answer use pillows to maintain a side-lying position as needed
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-
approximated edges and no signs of infection. How will the nurse document this assessment
finding? - correct answer incision
