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Skin Integrity and Wound Healing Nclex Questions and Answers (100% Pass)
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Skin Integrity and Wound Healing Nclex Questions and Answers (100% Pass)
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©PREP4EXAMS @2024 [REAL EXAM DUMPS] Wednesday, July 17, 2024 1:27 AMSkin Integrity and Wound Healing Nclex
Questions and Answers (100% Pass)
When repositioning an immobile patient, the nurse notices redness over a bony prominence.
What is indicated when a reddened area blanches on fingertip touch?
A. A local skin infection requiring antibiotics
B. Sensitive skin that requires special bed linen
C. A stage III pressure ulcer needing the appropriate dressing
D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic
episode. - ✔️✔️D. Blanching hyperemia, indicating the attempt by the body to overcome the
ischemic episode.
When repositioning an immobile patient, it is important to assess all bony prominences for
the presence of redness, which can be the first sign of impaired skin integrity. Pressing over
the area compresses the blood vessels in the area; and, if the integrity of the vessels is good,
the area turns lighter in color and then returns to the red color. However, if the area does not
blanch when pressure is applied, tissue damage is likely.
Which type of pressure ulcer is noted to have intact skin and may include changes in one or
more of the following: skin temperature (warmth or coolness), tissue consistency (firm or
soft), and/or pain?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV - ✔️✔️A. Stage I
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, ©PREP4EXAMS @2024 [REAL EXAM DUMPS] Wednesday, July 17, 2024 1:27 AM
A stage I pressure ulcer does not have a break in the skin but has a redness that does not
blanch. Depending on the skin color, there may be a discoloration; the area may feel warm
because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel
firm if there is edema in the area or soft if the blood flow is compromised. The patient may
report pain in the area.
When obtaining a wound culture to determine the presence of a wound infection, from where
should the specimen be taken?
A. Necrotic tissue
B. Wound drainage
C. Drainage on the dressing
D. Wound after it has first been cleaned with normal saline - ✔️✔️D. Wound after it has first
been cleaned with normal saline
Drainage that has been present on the wound surface can contain bacteria from the skin, and
the culture may not contain the true causative organisms of a wound infection.
By cleaning the area before obtaining the culture, the skin flora is removed.
After surgery the patient with a closed abdominal wound reports a sudden "pop" after
coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces
of small bowel are noted at the bottom of the now-opened wound. Which corrective
intervention should the nurse do first?
A. Allow the area to be exposed to air until all drainage has stopped
B. Place several cold packs over the area, protecting the skin around the wound
C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team;
this is likely to indicate a wound evisceration
D. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain
in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal
quickly - ✔️✔️C. Cover the area with sterile, saline-soaked towels and immediately notify the
surgical team; this is likely to indicate a wound evisceration
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