Florida International University NUR 3029: Fundamentals
FUND CHPT 48 SKIN/WOUND PART 2 QUESTIONS
WITH COMPLETE SOLUTIONS
4. The nurse is caring for a patient with potential skin
breakdown. Which components would the nurse include in the
skin assessment?
(Select all that apply.)
a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status Correct Answer 4. The nurse is caring for
a patient with potential skin breakdown. Which components
would the nurse include in the skin assessment?
(Select all that apply.)
a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status
43. The nurse is caring for a postoperative medial meniscus
repair of the right knee. To assist with pain management
following the
procedure, which intervention should the nurse implement?
,a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot. Correct Answer 43. The nurse is
caring for a postoperative medial meniscus repair of the right
knee. To assist with pain management following the
procedure, which intervention should the nurse implement?
a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot.
ANS: A
A partial-thickness wound repair has three compartments: the
inflammatory response, epithelial proliferation and migration,
and
re-establishment of the epidermal layers. Epithelial proliferation
and migration start at all edges of the wound, allowing for quick
resurfacing. Epithelial cells begin to migrate across the wound
bed soon after the wound occurs. A wound left open to air
resurfaces
within 6 to 7 days, whereas a wound that is kept moist can
resurface in 4 days. One or 2 days is too soon for this process to
occur,
moist or dry. Correct Answer 8. The nurse is caring for a
patient with a large abrasion from a motorcycle accident. The
nurse recalls that if the wound is kept moist,
it can resurface in _____ day(s).
,a. 4
b. 2
c. 1
d. 7
ANS: A
After determining that a patient's condition is stable, inspect the
wound for bleeding. An abrasion will have limited bleeding, a
laceration can bleed more profusely, and a puncture wound
bleeds in relation to the size and depth of the wound. Address
any
bleeding issues. Inspect the wound for foreign bodies; traumatic
wounds are dirty and may need to be addressed. Determine the
size
of the wound. A large open wound may expose bone or tissue
and be protected, or the wound may need suturing. When the
wound
is caused by a dirty penetrating object, determine the need for a
tetanus vaccination. Correct Answer A patient presents to the
emergency department with a laceration of the right forearm
caused by a fall. After determining that the
patient is stable, the next best step is to
a. Inspect the wound for bleeding.
b. Inspect the wound for foreign bodies.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.
ANS: A
, Assessment and skin hygiene are two initial defenses for
preventing skin breakdown. Avoid soaps and hot water when
cleansing the
skin. Use gentle cleansers with nonionic surfactants. After
bathing, make sure to dry the skin completely, and apply
moisturizer to
keep the epidermis well lubricated. Absorbent pads and
garments are controversial and should be considered only when
other
alternatives have been exhausted. Positioning the patient reduces
pressure and shearing force to the skin and is part of the plan of
care but is not one of the initial components. Depending on the
needs of the patient, a specialty bed may be needed, but again,
this
does not provide the initial defense for skin breakdown.
Correct Answer 36. The nurse is caring for a patient who has
suffered a stroke and has residual mobility problems. The patient
is at risk for skin
impairment. Which initial interventions should the nurse select
to decrease this risk?
a. Gentle cleaners and thorough drying of the skin
b. Absorbent pads and garments
c. Positioning with use of pillows
d. Therapeutic beds and mattresses
ANS: A
Normal wound healing requires proper nutrition. Serum proteins
are biochemical indicators of malnutrition, and serum albumin is
FUND CHPT 48 SKIN/WOUND PART 2 QUESTIONS
WITH COMPLETE SOLUTIONS
4. The nurse is caring for a patient with potential skin
breakdown. Which components would the nurse include in the
skin assessment?
(Select all that apply.)
a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status Correct Answer 4. The nurse is caring for
a patient with potential skin breakdown. Which components
would the nurse include in the skin assessment?
(Select all that apply.)
a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status
43. The nurse is caring for a postoperative medial meniscus
repair of the right knee. To assist with pain management
following the
procedure, which intervention should the nurse implement?
,a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot. Correct Answer 43. The nurse is
caring for a postoperative medial meniscus repair of the right
knee. To assist with pain management following the
procedure, which intervention should the nurse implement?
a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot.
ANS: A
A partial-thickness wound repair has three compartments: the
inflammatory response, epithelial proliferation and migration,
and
re-establishment of the epidermal layers. Epithelial proliferation
and migration start at all edges of the wound, allowing for quick
resurfacing. Epithelial cells begin to migrate across the wound
bed soon after the wound occurs. A wound left open to air
resurfaces
within 6 to 7 days, whereas a wound that is kept moist can
resurface in 4 days. One or 2 days is too soon for this process to
occur,
moist or dry. Correct Answer 8. The nurse is caring for a
patient with a large abrasion from a motorcycle accident. The
nurse recalls that if the wound is kept moist,
it can resurface in _____ day(s).
,a. 4
b. 2
c. 1
d. 7
ANS: A
After determining that a patient's condition is stable, inspect the
wound for bleeding. An abrasion will have limited bleeding, a
laceration can bleed more profusely, and a puncture wound
bleeds in relation to the size and depth of the wound. Address
any
bleeding issues. Inspect the wound for foreign bodies; traumatic
wounds are dirty and may need to be addressed. Determine the
size
of the wound. A large open wound may expose bone or tissue
and be protected, or the wound may need suturing. When the
wound
is caused by a dirty penetrating object, determine the need for a
tetanus vaccination. Correct Answer A patient presents to the
emergency department with a laceration of the right forearm
caused by a fall. After determining that the
patient is stable, the next best step is to
a. Inspect the wound for bleeding.
b. Inspect the wound for foreign bodies.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.
ANS: A
, Assessment and skin hygiene are two initial defenses for
preventing skin breakdown. Avoid soaps and hot water when
cleansing the
skin. Use gentle cleansers with nonionic surfactants. After
bathing, make sure to dry the skin completely, and apply
moisturizer to
keep the epidermis well lubricated. Absorbent pads and
garments are controversial and should be considered only when
other
alternatives have been exhausted. Positioning the patient reduces
pressure and shearing force to the skin and is part of the plan of
care but is not one of the initial components. Depending on the
needs of the patient, a specialty bed may be needed, but again,
this
does not provide the initial defense for skin breakdown.
Correct Answer 36. The nurse is caring for a patient who has
suffered a stroke and has residual mobility problems. The patient
is at risk for skin
impairment. Which initial interventions should the nurse select
to decrease this risk?
a. Gentle cleaners and thorough drying of the skin
b. Absorbent pads and garments
c. Positioning with use of pillows
d. Therapeutic beds and mattresses
ANS: A
Normal wound healing requires proper nutrition. Serum proteins
are biochemical indicators of malnutrition, and serum albumin is
