NCLEX Skin Integrity & Wound Care
Exam Questions And Answers
/What is an indication of proper use of a triangle arm sling?
1. The elbow is kept flexed at 90 degrees or more.
2. The knot is placed on either side of the vertebrae of the neck.
3. The sling extends to just proximal of the hand.
4. The sling is removed q2h to assess for circulation and skin integrity. - Answer-2. The
knot is placed on either side of the vertebrae of the neck; The knot of the triangle sling
must be kept off the spinal processes because this would be uncomfortable and put
unnecessary pressure on the vertebrae.
The elbow should be flexed slightly less than 80 degrees (not > 90 as in option 1) so the
hand is above the elbow to prevent dependent swelling. The sling must extend past the
wrist in order to support the hand. Although the sling must be removed to check for
circulation and skin integrity, every 2 hours (option 4) is unnecessarily frequent and
impractical.
/.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.
Collected drainage contains old and mixed organisms. An appropriate specimen can be
obtained without causing the client the discomfort of debriding. The nurse does not
generally debride a wound to obtain a specimen. Once systemic antibiotics have been
begun, the interval following a does will not significantly affect the concentration of
wound organisms.
/.Which of the following items are used to perform wound care irrigation? Select all that
apply.
1. Clean gloves
2. Sterile gloves
3. Refrigerated irrigating solution
4. 60-mL syringe - Answer-1, 2, and 4; To irrigate a wound, the nurse uses clean gloves
to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile
gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume
of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be at
room or body temperature-- certainly not refrigerated.
/.A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no
necrotic areas. The nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing indicated. - Answer-3. Hydrocolloid; Hydrocolloid dressings protect
shallow ulcers and maintain an appropriate healing environment.
Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2)
will stick to granulation tissue, causing more damage. A dressing is needed to protect
the wound and enhance healing.
/.Which of the following are primary risk factors for pressure ulcers? Select all that
apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed - Answer-1, 3, & 4; Risk factors for pressure ulcers include a
low-protein diet, lengthy surgical procedures, and fever.
Protein is needed for adequate skin health and healing. During surgery, the client is on
a hard surface and may not be well protected from pressure on bony prominences.
Exam Questions And Answers
/What is an indication of proper use of a triangle arm sling?
1. The elbow is kept flexed at 90 degrees or more.
2. The knot is placed on either side of the vertebrae of the neck.
3. The sling extends to just proximal of the hand.
4. The sling is removed q2h to assess for circulation and skin integrity. - Answer-2. The
knot is placed on either side of the vertebrae of the neck; The knot of the triangle sling
must be kept off the spinal processes because this would be uncomfortable and put
unnecessary pressure on the vertebrae.
The elbow should be flexed slightly less than 80 degrees (not > 90 as in option 1) so the
hand is above the elbow to prevent dependent swelling. The sling must extend past the
wrist in order to support the hand. Although the sling must be removed to check for
circulation and skin integrity, every 2 hours (option 4) is unnecessarily frequent and
impractical.
/.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.
Collected drainage contains old and mixed organisms. An appropriate specimen can be
obtained without causing the client the discomfort of debriding. The nurse does not
generally debride a wound to obtain a specimen. Once systemic antibiotics have been
begun, the interval following a does will not significantly affect the concentration of
wound organisms.
/.Which of the following items are used to perform wound care irrigation? Select all that
apply.
1. Clean gloves
2. Sterile gloves
3. Refrigerated irrigating solution
4. 60-mL syringe - Answer-1, 2, and 4; To irrigate a wound, the nurse uses clean gloves
to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile
gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume
of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be at
room or body temperature-- certainly not refrigerated.
/.A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no
necrotic areas. The nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing indicated. - Answer-3. Hydrocolloid; Hydrocolloid dressings protect
shallow ulcers and maintain an appropriate healing environment.
Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2)
will stick to granulation tissue, causing more damage. A dressing is needed to protect
the wound and enhance healing.
/.Which of the following are primary risk factors for pressure ulcers? Select all that
apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed - Answer-1, 3, & 4; Risk factors for pressure ulcers include a
low-protein diet, lengthy surgical procedures, and fever.
Protein is needed for adequate skin health and healing. During surgery, the client is on
a hard surface and may not be well protected from pressure on bony prominences.
