chapter 36 skin integrity and wound care real exam questions And Well detailed 100% explained answers.

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection - correct answer 3 The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the clients bowel resection. For which category of wound should the receiving nurse plan care for this client? 1. Clean-contaminated 2. Contaminated 3. Dirty 4. Infected - correct answer 2 A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for this clients care? 1. Obtain ice packs to apply to the wounds. 2. Request gauze to pack the wounds. 3. Organize suture material to close the wounds. 4. Notify the surgical staff that a surgical client will soon be arriving. - correct answer 1 After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? 1. Reactive hyperemia 2. Stage I pressure ulcer 3. Stage II pressure ulcer 4. Stage III pressure ulcer - correct answer 1 The nurse assesses an open area over a clients greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer? 1. There is undermining of adjacent tissues. 2. The crater extends into the subcutaneous tissue. 3. The joint capsule of the hip is visible. 4. The ulcer has thick dark eschar over the top. - correct answer 3 The UAP reports a small skin tear on the clients forearm that occurred during a routine turn. After assessing the wound the nurse should take which action? 1. Obtain a transparent dressing for the UAP to place on the wound. 2. Request a consult with the wound care nurse. 3. Cleanse the wound and apply a dressing. 4. Tell the UAP to reevaluate the wound in 20 minutes. - correct answer 3 The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse 1. should receive specific training. 2. must be certified. 3. is required to ask the clients permission. 4. has to obtain special assessment equipment. - correct answer 1 A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores? 1. Trending can only be accurate if the same scale is used. 2. There is a definite trend of low risk for pressure ulcer development. 3. Trending would be more accurate if the same scale was used. 4. The scores indicate opposite risks for pressure ulcer development. - correct answer 3 A clients laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing? 1. Primary intention 2. Open approximation 3. Secondary healing 4. Delayed closure - correct answer 1 A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause 1. decreased oxygen supply to tissues. 2. suppression of the inflammatory process necessary for healing. 3. a decrease in the amount of nutrients such as glucose in the blood. 4. blood vessel constriction, which impairs waste product removal. - correct answer 2 On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that something popped in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first? 1. Notify the clients surgeon. 2. Cover the area with a large saline-soaked dressing. 3. Position the client in bed with knees bent. 4. Pack the wound with nonadherent gauze. - correct answer 2 A client is prescribed antiembolic stockings. How should the nurse assess the skin on the clients legs? 1. Defer the assessment because the stockings are in place. 2. Remove the stockings for this assessment. 3. Review the morning assessment, but dont repeat it unless a problem occurs. 4. Assess the skin when the client removes the stockings at bedtime. - correct answer 2 Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take? 1. Place a tourniquet above the wound. 2. Remove the dressing and place direct pressure on the wound. 3. Add an additional dressing to the wound without removing the original. 4. Remove the dressing and replace it with a new sterile dressing - correct answer 3 The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected? 1. Clean areas of granulation tissue 2. Exudate in the bottom of the wound 3. A pus-coated area on the side of the wound 4. Intact skin at the edge of the wound - correct answer 1 The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client? 1. Altered Tissue Perfusion 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Injury - correct answer 3 The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing? 1. Materials used in dressing this wound should keep the wound bed moist. 2. The dressing should allow good air circulation through the wound. 3. Dressings should be simple as they will be changed at least every 4 hours. 4. Absorbent material to wick exudates away and support drying should be used. - correct answer 1 The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide? 1. Wash the area with soap and hot water at every brief change. 2. Apply a petroleum-based cream to the area after cleaning. 3. Wipe the skin with an alcohol-free barrier film agent after cleaning. 4. Keep the client in bed on absorbent pads until the area clears. - correct answer 3 The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the clients skin? 1. Keep the head of the clients bed at 30 degrees. 2. Coat the clients back and buttocks with baby powder after bathing. 3. Use a turn sheet lifted by two staff members to move the client in bed. 4. Dust the linens with cornstarch each morning to allow for easier movement. - correct answer 3 Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan? 1. Red 2. Yellow 3. Black 4. A combination of all three - correct answer 3 The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome? 1. The rubber doughnut pressure relief device was not delivered by central supply. 2. The clients serum albumin increased over the last month. 3. Nurses did not document disinfection of the wound with alcohol with each dressing change. 4. Unlicensed assistive personnel (UAP) followed a right sidebackleft sideback turning schedule. - correct answer 4 The nurse has applied an aquathermia pad to a clients back. After 15 minutes of treatment, the client says that the pack no longer is warm and asks the nurse to increase the temperature. H