Chapter 23 Skin Integrity and Wound Care

Chapter 23  Skin Integrity and Wound Care

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

1) A home care nurse is teaching a family member to apply a hydrocolloid dressing over a wound. 1)
Which statement made by the family member indicates that the teaching about the procedure has
been effective?

A) “If I notice any leakage, I’ll cover the dressing with one of those large sterile absorbent pads
you brought.”

B) “If I notice any moisture under the dressing, I will change it right away.”
C) “I’ll be sure to wash and dry the skin around the dressing each time I change it.”
D) “I’ll try to keep the dressing in place for at least a week. If it starts to come loose, I’ll tape the

sides.”
Answer: C
Explanation: A) A hydrocolloid dressing is designed to absorb exudates, produce a moist

environment, and protect a wound from contamination. Each time a dressing is
changed, the skin around the area should be gently washed with a mild cleansing
agent or normal saline. When dressings become loose, leak, or develop an odor
they should be changed.
Evaluation
Physiological Integrity – Reduction of Risk Potential
Analysis

B) A hydrocolloid dressing is designed to absorb exudates, produce a moist
environment, and protect a wound from contamination. Each time a dressing is
changed, the skin around the area should be gently washed with a mild cleansing
agent or normal saline. When dressings become loose, leak, or develop an odor
they should be changed.
Evaluation
Physiological Integrity – Reduction of Risk Potential
Analysis

C) A hydrocolloid dressing is designed to absorb exudates, produce a moist
environment, and protect a wound from contamination. Each time a dressing is
changed, the skin around the area should be gently washed with a mild cleansing
agent or normal saline. When dressings become loose, leak, or develop an odor
they should be changed.
Evaluation
Physiological Integrity – Reduction of Risk Potential
Analysis

D) A hydrocolloid dressing is designed to absorb exudates, produce a moist
environment, and protect a wound from contamination. Each time a dressing is
changed, the skin around the area should be gently washed with a mild cleansing
agent or normal saline. When dressings become loose, leak, or develop an odor
they should be changed.
Evaluation
Physiological Integrity – Reduction of Risk Potential
Analysis

1

2) Several hours after being catheterized, a client develops widespread erythema and pruritus in the 2)
perineal area, which extends to the lower abdomen and the inside aspects of the legs. The nurse
should recognize that these symptoms are most likely related to a/an:

A) Urinary tract infection from the catheterization.
B) Localized contact dermatitis from the bed linens.
C) Allergic response to a medication the client is taking.
D) Latex allergy from equipment used in the catheterization.

Answer: D
Explanation: A) The symptoms presented are associated with type 4 latex allergies (allergic contact

dermatitis). The symptoms are localized and occurred following a procedure in
which the client may have come into contact with latex equipment. These are not
the symptoms of a urinary tract infection. An allergy to bed linens would manifest
more widespread over the client’s body. Rashes from medication allergies typically
start on the torso and neck.
Assessment
Safe, Effective Care Environment – Safety and Infection Control
Analysis

B) The symptoms presented are associated with type 4 latex allergies (allergic contact
dermatitis). The symptoms are localized and occurred following a procedure in
which the client may have come into contact with latex equipment. These are not
the symptoms of a urinary tract infection. An allergy to bed linens would manifest
more widespread over the client’s body. Rashes from medication allergies typically
start on the torso and neck.
Assessment
Safe, Effective Care Environment – Safety and Infection Control
Analysis

C) The symptoms presented are associated with type 4 latex allergies (allergic contact
dermatitis). The symptoms are localized and occurred following a procedure in
which the client may have come into contact with latex equipment. These are not
the symptoms of a urinary tract infection. An allergy to bed linens would manifest
more widespread over the client’s body. Rashes from medication allergies typically
start on the torso and neck.
Assessment
Safe, Effective Care Environment – Safety and Infection Control
Analysis

D) The symptoms presented are associated with type 4 latex allergies (allergic contact
dermatitis). The symptoms are localized and occurred following a procedure in
which the client may have come into contact with latex equipment. These are not
the symptoms of a urinary tract infection. An allergy to bed linens would manifest
more widespread over the client’s body. Rashes from medication allergies typically
start on the torso and neck.
Assessment
Safe, Effective Care Environment – Safety and Infection Control
Analysis

3) The nurse would be least likely to consider potential problems with skin integrity when planning 3)
care for which of the following hospitalized clients?

A) An 85-year-old female with diabetes mellitus
B) A 25-year-old male who received multiple abrasions in a motor vehicle accident
C) A 50-year-old female with pneumonia
D) A 45-year-old male in skeletal traction

Answer: C

2

Explanation: A) The potential for problems with skin integrity is greatest in older adults and in
clients with diagnoses that limit mobility, affect peripheral circulation, and break
the integrity of the skin (i.e., trauma, surgery). The 25-year-old male, 45-year-old
male, and 85-year-old female all have one or more of these risk factors. The
50-year-old female has no risk or is at minimal risk because of her age and
diagnosis.
Planning
Physiological Integrity – Reduction of Risk Potential
Application

B) The potential for problems with skin integrity is greatest in older adults and in
clients with diagnoses that limit mobility, affect peripheral circulation, and break
the integrity of the skin (i.e., trauma, surgery). The 25-year-old male, 45-year-old
male, and 85-year-old female all have one or more of these risk factors. The
50-year-old female has no risk or is at minimal risk because of her age and
diagnosis.
Planning
Physiological Integrity – Reduction of Risk Potential
Application

C) The potential for problems with skin integrity is greatest in older adults and in
clients with diagnoses that limit mobility, affect peripheral circulation, and break
the integrity of the skin (i.e., trauma, surgery). The 25-year-old male, 45-year-old
male, and 85-year-old female all have one or more of these risk factors. The
50-year-old female has no risk or is at minimal risk because of her age and
diagnosis.
Planning
Physiological Integrity – Reduction of Risk Potential
Application

D) The potential for problems with skin integrity is greatest in older adults and in
clients with diagnoses that limit mobility, affect peripheral circulation, and break
the integrity of the skin (i.e., trauma, surgery). The 25-year-old male, 45-year-old
male, and 85-year-old female all have one or more of these risk factors. The
50-year-old female has no risk or is at minimal risk because of her age and
diagnosis.
Planning
Physiological Integrity – Reduction of Risk Potential
Application

4) A nurse is preparing to obtain wound cultures from three different wounds on a client’s leg. The 4)
nurse collects three commercially prepared culturette kits and prepares to obtain the specimens.
When collecting the three specimens, it is essential that the nurse:

A) Premedicate the client prior to the procedure.
B) Avoid contaminating any of the three specimens and specimen containers.
C) Clean the wounds after collecting the specimens.
D) Wear sterile gloves.

Answer: B

3

Explanation: A) A culture specimen must be kept free from contamination by anything other than
what is obtained from the wound or culture site. An incorrect culture sample can
lead to an incorrect diagnosis and treatment. Culturette kits have a cue tip that is
long enough to keep the nurse’s hands at a distance from the culture site. Although
the swab is long enough to keep the nurse’s hands away from the open areas,
gloves should still be worn. The gloves do not need to be sterile. The leg wounds
should be cleaned of old exudates prior to collecting the specimens. Obtaining
wound cultures is generally not painful and there is no indication in the scenario
that it will be a painful procedure.
Implementation
Safe, Effective Care Environment – Safety and Infection Control
Application

B) A culture specimen must be kept free from contamination by anything other than
what is obtained from the wound or culture site. An incorrect culture sample can
lead to an incorrect diagnosis and treatment. Culturette kits have a cue tip that is
long enough to keep the nurse’s hands at a distance from the culture site. Although
the swab is long enough to keep the nurse’s hands away from the open areas,
gloves should still be worn. The gloves do not need to be sterile. The leg wounds
should be cleaned of old exudates prior to collecting the specimens. Obtaining
wound cultures is generally not painful and there is no indication in the scenario
that it will be a painful procedure.
Implementation
Safe, Effective Care Environment – Safety and Infection Control
Application

C) A culture specimen must be kept free from contamination by anything other than
what is obtained from the wound or culture site. An incorrect culture sample can
lead to an incorrect diagnosis and treatment. Culturette kits have a cue tip that is
long enough to keep the nurse’s hands at a distance from the culture site. Although
the swab is long enough to keep the nurse’s hands away from the open areas,
gloves should still be worn. The gloves do not need to be sterile. The leg wounds
should be cleaned of old exudates prior to collecting the specimens. Obtaining
wound cultures is generally not painful and there is no indication in the scenario
that it will be a painful procedure.
Implementation
Safe, Effective Care Environment – Safety and Infection Control
Application

D) A culture specimen must be kept free from contamination by anything other than
what is obtained from the wound or culture site. An incorrect culture sample can
lead to an incorrect diagnosis and treatment. Culturette kits have a cue tip that is
long enough to keep the nurse’s hands at a distance from the culture site. Although
the swab is long enough to keep the nurse’s hands away from the open areas,
gloves should still be worn. The gloves do not need to be sterile. The leg wounds
should be cleaned of old exudates prior to collecting the specimens. Obtaining
wound cultures is generally not painful and there is no indication in the scenario
that it will be a painful procedure.
Implementation
Safe, Effective Care Environment – Safety and Infection Control
Application