SKIN INTEGRITY & WOUND CARE
FINAL EXAM 2024
Which task can be delegated to assistive personnel (AP) in caring for a patient who has
pressure ulcers? - ANS✔✔--Applying an elastic bandage
Which fluids if exposed to the skin pose the highest risk of skin breakdown? -
ANS✔✔--Gastric secretions
Which condition does nonblanchable erythema indicate about the skin tissue? -
ANS✔✔--Damage
A long-term care facility encourages nurses to assess patients at risk of developing
pressure injuries based on six subscales: moisture, sensory perception, activity,
mobility, nutrition, and friction or shear force. Which tool is the long-term care facility
using for risk assessment of pressure injury development? - ANS✔✔--Braden Scale
Which stage of pressure injury is noted to have intact skin and may include changes in
skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? -
ANS✔✔--Stage 1
While assessing a patient who has a pressure injury, the nurse finds black wound
tissue. In which stage is this pressure injury? - ANS✔✔--Unstageable
Which support surface is useful for treating and preventing pulmonary, venous stasis,
and urinary complications associated with immobility? - ANS✔✔--Lateral rotation
surface
Which nutrient supports healing by promoting wound closure? - ANS✔✔--Vitamin A
Which vitamin should be provided to a patient to promote wound healing? - ANS✔✔--
Vitamin A & C
Which finding is characteristic of a stage 3 pressure injury? - ANS✔✔--It has full-
thickness skin loss
The subcutaneous fat may be visible
Neither the bone, tendon, nor muscle is exposed
The nurse assesses a patient's abdominal wound and finds that the wound is in the
proliferative phase of healing. Which change in the wound might have led the nurse to
this conclusion? - ANS✔✔--The wound is filled with granulation tissue
, The wound contracts to reduce the area that requires healing
There is reepithelialization of the wound surface
Which term is used to describe deteriorated skin condition related to prolonged,
unrelieved pressure on a body part? - ANS✔✔--Bedsore
Pressure sore
Pressure ulcer
Decubitus ulcer
Which statement regarding the skin is true? - ANS✔✔--The dermis and the inner
layer of the skin provide tensile strength
Which criteria does the Braden Scale evaluate? - ANS✔✔--Risk factors that place the
patient at risk of pressure injury
Which type of dressing is used for stage 1 pressure ulcers? - ANS✔✔--Transparent
film dressings
Which task can be delegated to assistive personnel (AP)? - ANS✔✔--Securing the
dressing using special tapes
Why would the nurse clean a wound with normal saline using an irrigating syringe? -
ANS✔✔--To remove wound debris
Which type of gauze should be used for dressing a wound on the palm? - ANS✔✔--
Elastic net
The nurse observes that a patient's ulcer is very slow to heal. Which action made by the
nurse can help facilitate faster healing of the patient's wound? - ANS✔✔--Assessing
the ulcer during each dressing change
Which type of dressing is preferred for dry wounds? - ANS✔✔--Hydrogel
A patient developed a pressure ulcer after knee surgery because of restriction to bed.
Which irrigating fluid should the nurse use to clean the ulcer? - ANS✔✔--Normal
saline
Which items would be required for wound irrigation? - ANS✔✔--Gauze dressing
supplies
FINAL EXAM 2024
Which task can be delegated to assistive personnel (AP) in caring for a patient who has
pressure ulcers? - ANS✔✔--Applying an elastic bandage
Which fluids if exposed to the skin pose the highest risk of skin breakdown? -
ANS✔✔--Gastric secretions
Which condition does nonblanchable erythema indicate about the skin tissue? -
ANS✔✔--Damage
A long-term care facility encourages nurses to assess patients at risk of developing
pressure injuries based on six subscales: moisture, sensory perception, activity,
mobility, nutrition, and friction or shear force. Which tool is the long-term care facility
using for risk assessment of pressure injury development? - ANS✔✔--Braden Scale
Which stage of pressure injury is noted to have intact skin and may include changes in
skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? -
ANS✔✔--Stage 1
While assessing a patient who has a pressure injury, the nurse finds black wound
tissue. In which stage is this pressure injury? - ANS✔✔--Unstageable
Which support surface is useful for treating and preventing pulmonary, venous stasis,
and urinary complications associated with immobility? - ANS✔✔--Lateral rotation
surface
Which nutrient supports healing by promoting wound closure? - ANS✔✔--Vitamin A
Which vitamin should be provided to a patient to promote wound healing? - ANS✔✔--
Vitamin A & C
Which finding is characteristic of a stage 3 pressure injury? - ANS✔✔--It has full-
thickness skin loss
The subcutaneous fat may be visible
Neither the bone, tendon, nor muscle is exposed
The nurse assesses a patient's abdominal wound and finds that the wound is in the
proliferative phase of healing. Which change in the wound might have led the nurse to
this conclusion? - ANS✔✔--The wound is filled with granulation tissue
, The wound contracts to reduce the area that requires healing
There is reepithelialization of the wound surface
Which term is used to describe deteriorated skin condition related to prolonged,
unrelieved pressure on a body part? - ANS✔✔--Bedsore
Pressure sore
Pressure ulcer
Decubitus ulcer
Which statement regarding the skin is true? - ANS✔✔--The dermis and the inner
layer of the skin provide tensile strength
Which criteria does the Braden Scale evaluate? - ANS✔✔--Risk factors that place the
patient at risk of pressure injury
Which type of dressing is used for stage 1 pressure ulcers? - ANS✔✔--Transparent
film dressings
Which task can be delegated to assistive personnel (AP)? - ANS✔✔--Securing the
dressing using special tapes
Why would the nurse clean a wound with normal saline using an irrigating syringe? -
ANS✔✔--To remove wound debris
Which type of gauze should be used for dressing a wound on the palm? - ANS✔✔--
Elastic net
The nurse observes that a patient's ulcer is very slow to heal. Which action made by the
nurse can help facilitate faster healing of the patient's wound? - ANS✔✔--Assessing
the ulcer during each dressing change
Which type of dressing is preferred for dry wounds? - ANS✔✔--Hydrogel
A patient developed a pressure ulcer after knee surgery because of restriction to bed.
Which irrigating fluid should the nurse use to clean the ulcer? - ANS✔✔--Normal
saline
Which items would be required for wound irrigation? - ANS✔✔--Gauze dressing
supplies
