Chapter 31 Skin Integrity and Wound Care

Chapter 31  Skin Integrity and Wound Care

Complete Chapter Questions And Answers
 

Sample Questions

1.
Upon assessment of a client’s wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse’s assessment?
A)
Proliferation phase
B)
Hemostasis
C)
Inflammatory phase
D)
Maturation phase
Ans:
A

Feedback:

The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms.

2.
Upon responding to the client’s call bell, the nurse discovers the client’s wound has dehisced. Initial nursing management includes calling the physician and doing which of the following?
A)
Covering the wound area with sterile towels moistened with sterile 0.9% saline
B)
Closing the wound area with Steri-Strips
C)
Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze
D)
Holding the wound together until the physician arrives
Ans:
A

Feedback:

If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The client should also be placed in the low Fowler’s position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone.

3.
The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound?
A)
Stage I pressure ulcer
B)
Stage II pressure ulcer
C)
Stage III pressure ulcer
D)
Stage IV pressure ulcer
Ans:
C

Feedback:

Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction associated with full-thickness skin loss is categorized as a stage IV pressure ulcer. A stage I ulcer is a defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in darker pigmented skin. A stage II pressure ulcer is superficial and may present as a blister or abrasion.

4.
When measuring the size, depth, and wound tunneling of a client’s stage IV pressure ulcer, what action should the nurse perform first?
A)
Perform hand hygiene.
B)
Insert a swab into the wound at 90 degrees.
C)
Measure the width of the wound with a disposable ruler.
D)
Assess the condition of the visible wound bed.
Ans:
A

Feedback:

Hand hygiene should precede any wound assessment or wound treatment.

5.
The nurse would recognize which of these devices as an open drainage system?
A)
Penrose drain
B)
Jackson-Pratt drain
C)
Hemovac
D)
Negative pressure dressing
Ans:
A

Feedback:

A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems.