CHAPTER 29: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 29: Skin Integrity and Wound Care Multiple Choice Questions 1. Which of the following descriptions would be classified as a closed wound? A. A large bruise on the side of the face B. A surgical incision that is sutured closed C. A puncture wound that is healing D. An abrasion on the leg Answer: A Explanation: A closed wound involves intact skin, such as a bruise, whereas open wounds (incisions, punctures, abrasions) have breaks in the skin surface. Why Other Options Are Wrong: B, C, and D are incorrect because they describe open wounds with broken skin. 2. Which statement by a patient about wound infection signs indicates a need for further education? A. "The wound will be red." B. "The wound will have pus." C. "The wound will be warm." D. "The wound will need to be treated." Answer: B Explanation: While pus may occur, infected wounds primarily show redness, warmth, and increased drainage (not necessarily purulent). Why Other Options Are Wrong: A, C, and D are correct indicators of infection. 3. Which type of wound heals by tertiary intention? A. An acute wound with sutures placed immediately B. A pressure ulcer treated with dressing changes C. An acute wound closed with surgical glue D. A wound left open initially and sutured later Answer: D Explanation: Tertiary intention involves delayed closure after initial left-open management. Why Other Options Are Wrong: A heals by primary intention; B by secondary; C by primary. 4. A postoperative abdominal surgery patient reports a "popping sensation" and wet dressing. What complication should the nurse suspect? A. Wound infection B. Loose stitches C. Wound dehiscence D. Wound crepitus Answer: C Explanation: Dehiscence involves tissue layer separation, often with a popping sensation and drainage. Why Other Options Are Wrong: A lacks popping; B doesn’t cause wetness; D involves air under skin. 5. What should the nurse do first for a postoperative patient with complete wound evisceration? A. Cover with dry sterile gauze B. Apply a transparent dressing C. Press on the wound with gauze D. Cover with saline-soaked gauze Answer: D Explanation: Moist saline gauze prevents drying and further complications until surgical intervention. Why Other Options Are Wrong: A can dry the wound; B is for debridement; C may worsen injury. 6. What is the most appropriate goal for a stage 3 pressure ulcer with the diagnosis Impaired skin integrity? A. Heal completely in 72 hours B. Show healing signs within 2 weeks C. Prevent new pressure ulcers D. Ambulate twice daily Answer: B Explanation: Stage 3 ulcers require time to heal; 2 weeks is realistic for initial progress. Why Other Options Are Wrong: A is unrealistic; C is a general goal; D is an intervention. 7. Which action by a new nurse delegating wound care to a UAP requires intervention? A. Asking the UAP to assess the wound B. Requesting drainage monitoring C. Asking about dietary changes D. Delegating dressing changes Answer: A Explanation: Assessment is a nursing responsibility and cannot be delegated. Why Other Options Are Wrong: B, C, and D are appropriate UAP tasks. 8. To prevent pressure ulcers in a side-lying position, how should the nurse position the bed? A. Flat B. 90 degrees C. 30 degrees D. 45 degrees Answer: C Explanation: 30 degrees avoids direct pressure on bony prominences like the trochanter. Why Other Options Are Wrong: A and B increase pressure; D is less effective than 30 degrees. 9. Which intervention is not a form of mechanical debridement? A. Wet-to-dry dressings B. Whirlpool baths C. Wet-to-damp dressings D. Enzymatic dressing Answer: D Explanation: Enzymatic debridement uses chemical agents, not mechanical methods like dressings or whirlpools. Why Other Options Are Wrong: A, B, and C are mechanical debridement techniques. 10. Which statement about occlusive dressings indicates a student’s lack of understanding? A. "They are used for autolytic debridement." B. "Hydrocolloids are occlusive." C. "They can be used on infected wounds." D. "They support comfortable debridement." Answer: C Explanation: Occlusive dressings are contraindicated for infected wounds due to moisture retention. Why Other Options Are Wrong: A, B, and D are accurate statements. 11. Which wound type is appropriate for a hydrocolloid dressing? A. Heavy drainage B. Tunneling C. Stapled incision D. Moderate drainage Answer: D Explanation: Hydrocolloids absorb small-to-moderate drainage and form a gel over 3–7 days. Why Other Options Are Wrong: A requires foam/alginate; B may need packing; C requires Steri Strips/gauze. 12. What care is needed for a Penrose drain? A. Compress after emptying B. Connect to suction C. Avoid dislodging (not sutured) D. Allow suction re-expansion Answer: C Explanation: Penrose drains are open, unsutured tubes requiring careful handling to prevent dislodgment. Why Other Options Are Wrong: A and B apply to closed drains; D describes suction drain function. 13. Which statement about home heat/cold therapy indicates a need for further education? A. "Fill ice bags 2/3 full." B. "Use distilled water in Aqua-K pads." C. "Microwave hot packs." D. "Follow order for compress duration." Answer: C Explanation: Microwaving hot packs (unless designed for it) risks burns and uneven heating. Why Other Options Are Wrong: A, B, and D are correct practices. 14. Which syringe is used to irrigate a deep wound? A. 5-mL B. 10-mL C. 3-mL D. 30-mL Answer: D Explanation: A 30–50 mL syringe with an 18-gauge angiocath delivers 4–15 psi for effective irrigation. Why Other Options Are Wrong: Smaller syringes lack adequate pressure. 15. Why is drying a wound after irrigation important? A. Ensure dressing adhesion B. Maintain occlusion C. Prevent moisture-related skin breakdown D. Avoid infection from irrigant Answer: C Explanation: Drying reduces moisture-induced skin damage while patting minimizes tissue trauma. Why Other Options Are Wrong: A and B depend on dressing type; D is unrelated to drying. 16. What should the nurse do if a patient complains of severe pain during a wet-to-dry dressing change? A. Notify the provider B. Call the wound nurse C. Stop the procedure D. Administer pain medication Answer: C Explanation: Stopping immediately assesses whether pain is procedure-related or preexisting. Why Other Options Are Wrong: A, B, or D may follow after stopping and evaluating. 17. What is an appropriate goal for a stage 3 pressure ulcer patient with Impaired physical mobility? A. Remain infection-free during hospitalization B. Report pain management strategies C. Assist with position changes using a trapeze in 1 week D. Meet nutritional needs in 1 week Answer: C Explanation: Mobility improvement aligns with the nursing diagnosis and is measurable. Why Other Options Are Wrong: A relates to tissue integrity; B to pain; D to nutrition. 18. Which description defines a stage 3 pressure ulcer? A. Exposes bone/connective tissue B. Does not extend through fascia C. No tunneling present D. Partial-thickness epidermis wound Answer: B Explanation: Stage 3 ulcers involve subcutaneous tissue but not deeper structures (muscle/bone). Why Other Options Are Wrong: A describes stage 4; C is incorrect (tunneling may occur); D describes stage 2. 19. Which skin layer supplies dermal blood flow, insulation, and cushioning? A. Stratum germinativum B. Epidermis C. Subcutaneous layer D. Stratum corneum Answer: C Explanation: The subcutaneous layer provides vascular supply, insulation, and cushioning. Why Other Options Are Wrong: A produces new cells; B is the outermost layer; D consists of dead cells. MULTIPLE RESPONSE QUESTIONS 1. Which factors delay wound healing? (Select all that apply.) A. Diabetes B. COPD C. Repositioning on bed rest D. Obesity with excessive sweating E. Long-term steroid therapy Answer: A, B, D, E Explanation: Diabetes, COPD, obesity, and steroids impair healing via vascular, nutritional, or immune effects. Repositioning prevents ulcers but doesn’t delay healing. Why Other Options Are Wrong: C reduces pressure ulcer risk but doesn’t directly affect healing. 2. What causes pressure ulcers? (Select all that apply.) A. Pressure intensity B. Pressure duration C. Tissue tolerance D. Age E. Nutritional status Answer: A, B, C, D, E Explanation: Pressure ulcers result from intensity/duration of pressure, tissue tolerance, and factors like age/nutrition. Why Other Options Are Wrong: All options are correct contributors. 3. What should a focused wound assessment include? (Select all that apply.) A. Location/size B. Wound bed characteristics C. Response to treatment D. Pain level E. Drainage presence Answer: A, B, C, E Explanation: Assessments include location, size, bed condition, drainage, and treatment response. Pain is documented separately. Why Other Options Are Wrong: D is part of pain assessment, not wound-specific. 4. Which Braden scale categories assess pressure ulcer risk? (Select all that apply.) A. Activity B. Friction/shear C. Moisture D. Sensory perception E. Cognition Answer: A, B, C, D Explanation: The Braden scale evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Why Other Options Are Wrong: E is not a Braden scale category. 5. What interventions apply to Hemovac drains? (Select all that apply.) A. Measure drainage before emptying B. Label and record drains separately C. Recompress after emptying D. Secure above wound level E. Check for tubing kinks Answer: B, C, E Explanation: Labeling, recompressing, and checking for kinks maintain drain function. Secure below the wound to promote drainage. Why Other Options Are Wrong: A is incorrect (measure during emptying); D risks backflow. 6. When is cold therapy contraindicated? (Select all that apply.) A. Edema B. Shivering C. Bleeding D. Circulatory problems E. Advanced age Answer: A, B, D Explanation: Cold worsens edema (slows reabsorption), circulatory issues (vasoconstriction), and causes discomfort if shivering. Why Other Options Are Wrong: C is a heat therapy contraindication; E requires monitoring but isn’t a contraindication.