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NR 226 CHAPTER 48 QUIZ
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NR 226 CHAPTER 48 QUIZChapter 48: Skin Integrity and Wound Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is working on a medical-surgical unit that has been participating in a research
project associated with pressure ulcers. Which risk factor will the nurse assess for that
predisposes a patient to pressure ulcer development?
a. Decreased level of consciousness
b. Adequate dietary intake
c. Shortness of breath
d. Muscular pain
ANS: A
Patients who are confused or disoriented or who have changing levels of consciousness are
unable to protect themselves. The patient may feel the pressure but may not understand what
to do to relieve the discomfort or to communicate that he or she is feeling discomfort.
Impaired sensory perception, impaired mobility, shear, friction, and moisture are other
predisposing factors. Shortness of breath, muscular pain, and an adequate dietary intake are
not included among the predisposing factors.
DIF: Understand (comprehension) REF: 1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Assessment MSC: Reduction of Risk Potential
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago.
The patient sustained a head injury and is unconscious. Which priority element will the nurse
consider when planning care to decrease the development of a decubitus ulcer?
a. Resistance
b. Pressure
c. Weight
d. Stress
ANS: B
Pressure is the main element that causes pressure ulcers. Three pressure-related factors
contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue
tolerance. When the intensity of the pressure exerted on the capillary exceeds 15 to 32 mm
Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High
pressure over a short time and low pressure over a long time cause skin breakdown.
Resistance, stress, and weight are not the priority causes of pressure ulcers.
DIF: Understand (comprehension) REF: 1185-1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Planning MSC: Reduction of Risk Potential
3. Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
a. The patient has fecal incontinence.
b. The patient ate two thirds of breakfast.
, c. The patient has a raised red rash on the right shin.
d. The patient’s capillary refill is less than 2 seconds.
ANS: A
The presence and duration of moisture on the skin increase the risk of ulcer formation by
making it susceptible to injury. Moisture can originate from wound drainage, excessive
perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance
the opportunity for skin breakdown because the skin is moistened and softened, causing
maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the
meal does not indicate that the individual is at risk. A raised red rash on the leg again is a
concern and can affect the integrity of the skin, but it is located on the shin, which is not a
high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin
breakdown, but this capillary response is within normal limits.
DIF: Understand (comprehension) REF: 1187
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Assessment MSC: Reduction of Risk Potential
4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a
patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is
observed. How should the nurse document this ulcer in the patient’s medical record?
a. Stage I pressure ulcer
b. Healing Stage II pressure ulcer
c. Healing Stage III pressure ulcer
d. Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage
and is labeled with the words “healing stage” or healing Stage III pressure ulcer. Once an
ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage
III, and it cannot return to a previous stage such as Stage I or II. This ulcer is healing, so it is
no longer labeled a Stage III.
DIF: Understand (comprehension) REF: 1187
OBJ: Describe the pressure ulcer staging system. TOP: Implementation
MSC: Physiological Adaptation
5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse
notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How
will the nurse stage this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
, This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss
involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or
shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence.
With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and
muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone,
tendon, or muscle.
DIF: Apply (application) REF: 1187-1188
OBJ: Describe the pressure ulcer staging system. TOP: Assessment
MSC: Physiological Adaptation
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which
item should the nurse use first to assist in staging an ulcer on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately
complete the first step in assessment—inspection—and the entire assessment process. Natural
light or a halogen light is recommended. Fluorescent light sources can produce blue tones on
darkly pigmented skin and can interfere with an accurate assessment. Other items that could
possibly be used during the assessment include gloves for infection control, a disposable
measuring device to measure the size of the wound, and a cotton-tipped applicator to measure
the depth of the wound, but these items are not the first items used.
DIF: Understand (comprehension) REF: 1186
OBJ: Describe the pressure ulcer staging system. TOP: Assessment
MSC: Health Promotion and Maintenance
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?
a. Partial-thickness wound repair
b. Full-thickness wound repair
c. Primary intention
d. Tertiary intention
ANS: B
Stage IV pressure ulcers are full-thickness wounds that extend into the dermis and heal by
scar formation because the deeper structures do not regenerate, hence the need for full-
thickness repair. The full-thickness repair has four phases: hemostasis, inflammatory,
proliferative, and maturation. A wound heals by primary intention when wounds such as
surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk
for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are
shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds
heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a
wound is left open for several days, and then the wound edges are approximated. Wound
closure is delayed until risk of infection is resolved.
DIF: Apply (application) REF: 1187 | 1190
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