Fundamentals of Nursing Chapter 48: Skin Integrity
and Wound Care Practice questions
ANS: A
A partial-thickness wound repair has three compartments: the inflammatory response, epithelial
proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation
and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells
begin to migrate across the wound bed soon after the wound occurs. A wound left open to air
resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One
or 2 days is too soon for this process to occur, moist or dry. - ANS-8. The nurse is caring for a
patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is
kept moist, it can resurface in _____ day(s).
a. 4
b. 2
c. 1
d. 7
ANS: A
After determining that a patient's condition is stable, inspect the wound for bleeding. An
abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture
wound bleeds in relation to the size and depth of the wound. Address any bleeding issues.
Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be
addressed. Determine the size of the wound. A large open wound may expose bone or tissue
and be protected, or the wound may need suturing. When the wound is caused by a dirty
penetrating object, determine the need for a tetanus vaccination. - ANS-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, the next best step is to
a. Inspect the wound for bleeding.
b. Inspect the wound for foreign bodies.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.
ANS: A
Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid
soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants.
After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis
well lubricated. Absorbent pads and garments are controversial and should be considered only
when other alternatives have been exhausted. Positioning the patient reduces pressure and
shearing force to the skin and is part of the plan of care but is not one of the initial components.
Depending on the needs of the patient, a specialty bed may be needed, but again, this does not
provide the initial defense for skin breakdown. - ANS-36. The nurse is caring for a patient who
,has suffered a stroke and has residual mobility problems. The patient is at risk for skin
impairment. Which initial interventions should the nurse select to decrease this risk?
a. Gentle cleaners and thorough drying of the skin
b. Absorbent pads and garments
c. Positioning with use of pillows
d. Therapeutic beds and mattresses
ANS: A
Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of
malnutrition, and serum albumin is probably the most frequently measured of these parameters.
The best measurement of nutritional status is prealbumin because it reflects not only what the
patient has ingested, but also what the body has absorbed, digested, and metabolized.
Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known
role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic
activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission
and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation
of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer.
Vitamin E has no known role in wound healing. - ANS-15. A patient has developed a decubitus
ulcer. What laboratory data would be important to gather?
a. Serum albumin
b. Creatine kinase
c. Vitamin E
d. Potassium
ANS: A
occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It
involves abdominal surgical wounds and occurs after a sudden strain such as coughing,
vomiting, or sitting up in bed. Patients often report feeling as though something has given way.
Evisceration is seen when vital organs protrude through a wound opening. A fistula is an
abnormal passage between two organs or between an organ and the outside of the body that
can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is
odorous and purulent. - ANS-14. Which of these findings if seen in a postoperative patient
should the nurse associate with dehiscence?
a. Complaint by patient that something has given way
b. Protrusion of visceral organs through a wound opening
c. Chronic drainage of fluid through the incision site
d. Drainage that is odorous and purulent
ANS: A
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 12 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 (the
, ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and
weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes
of pressure ulcers. - ANS-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. The nurse is
able to identify that the major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.
ANS: A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do
not require a dressing. This allows visual inspection and monitoring. A transparent dressing
could be used to protect the patient from shear but cannot be used in the presence of excessive
moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A
hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be
utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be
utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing
of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry
and intact, no dressing is used, but this is an unstaged ulcer. - ANS-39. The nurse is staffing a
medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has
become competent in the care of pressure wounds and recognizes that a staged pressure ulcer
that does not require a dressing is stage
a. I.
b. II.
c. III.
d. IV.
ANS: A
The area on the heel has experienced a decreased supply of blood and oxygen (tissue
perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with
this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced
nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this
nursing diagnosis. - ANS-30. The nurse has collected the following assessment data: right heel
with reddened area that does not blanch. What nursing diagnosis would the nurse assign?
a. Ineffective tissue perfusion
b. Risk for infection
c. Imbalanced nutrition: less than body requirements
d. Acute pain
ANS: A
The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue
pressure damage includes visual and tactile inspection of the skin. Observe pressure points
such as bony prominences and areas next to treatments such as a binasal cannula and the
