Chapter 48: Skin Integrity and Wound Care

1. A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?

2. The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development of a decubitus ulcer?

3. Which nursing observation will indicate the patient is at risk for pressure ulcer formation?

4. The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient’s medical record?

5. The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

6. Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?

7. The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?

8. The nurse is caring for a group of patients. Which patient will the nurse see first?

9. The nurse is caring for a patient who is experiencing a full-thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing?

10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

11. The nurse caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient?

12. Which nursing observation will indicate the patient’s wound healed by the process of secondary intention?

13. The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the patient is experiencing a complication of wound healing?

14. Which finding will alert the nurse to a potential wound dehiscence?

15. Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer?

16. A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

17. Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to?

18. The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian?

19. The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain is currently in place. Which statement by the patient indicates issues with self-concept?

20. 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, what is the next best step for the nurse to take?

21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially?

23. The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?

24. The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?

25. The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider’s order will the nurse question?

26. The nurse is completing an assessment of the patient’s skin’s integrity. Which assessment is the priority?

27. The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?

28. The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient’s willingness and ability to increase mobility?

29. The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan?

30. The nurse documents the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?

31. The nurse caring for an immobile patient wants to decrease the risk of the formation of pressure ulcers. Which action will the nurse take first?

32. Which health care team member will the nurse consult when a patient has received a nursing diagnosis of Impaired skin integrity?

33. When a comatose patient develops a Stage II pressure ulcer, the nurse includes the nursing diagnosis of Risk for infection to the care plan. Which is the best goal for this patient?

34. When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)?

35. The nurse performing a moist-to-dry dressing has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the following steps, starting with the first one?1. Apply sterile gloves. 2. Cover and secure topper dressing. 3. Assess wound and surrounding skin. 4. Moisten gauze with prescribed solution. 5. Gently wring out excess solution and unfold. 6. Loosely pack until all wound surfaces are in contact with gauze.

36. The nurse is caring for a patient at risk for skin impairment. Which initial action should the nurse take to decrease this risk?

37. A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair?

38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?

39. As prescribed, the nurse leaves the pressure ulcer open to air and does not apply a dressing. Which stage of ulcer did the nurse appropriately treat?

40. The patient appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take?

41. Which intervention should be included as the nurse cleanses a wound?

42. Which is the best explanation for the nurse to provide when teaching the patient the reason for the binder after an open abdominal aortic aneurysm repair?

43. The nurse is caring for a postoperative patient recovering from a medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?

44. The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

1. The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.)

2. The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.)

3. The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)

4. The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)

5. The nurse is caring for a patient who will have a large abdominal bandage secured with an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.)

6. The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.)