NUR 335 Tissue Integrity Review Questions and Correct Answers
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Course
NUR 335
Institution
NUR 335
Which type of dressing is used for a stage III pressure ulcer? Calcium alginate
Calcium alginate absorbs exudate from the wound while maintaining a moist wound environment to promote rapid healing. Calcium alginate, along with a secondary dressing, is used to dress stage III pressure ulcers. Adher...
NUR 335 Tissue Integrity Review
Questions and Correct Answers
Which type of dressing is used for a stage III pressure ulcer? ✅Calcium alginate
Calcium alginate absorbs exudate from the wound while maintaining a moist wound
environment to promote rapid healing. Calcium alginate, along with a secondary
dressing, is used to dress stage III pressure ulcers. Adherent film is used to cover
unstageable pressure ulcers. Composite film dressing is used for stage II pressure
ulcers. A transparent dressing is used to dress stage I pressure ulcers.
The nurse is changing the dressing of a patient with a drain placed at the surgical site.
The nurse notices that the collecting device has minimal drainage, which is much less
than expected. What does the nurse suspect based on this observation? ✅Blockage in
the drainage tube
When there is a sudden decrease in the amount of drainage through a drain, the nurse
should suspect a blocked drain. The nurse should inspect the drain and tubing, and
inform the health care provider. A sudden decrease in the drainage does not indicate
accelerated wound healing. The drain needs to be advanced when there is a gradual
decrease in the drainage. A dislodged drain would be visually evident.
Which factor increases the risk of wound infection? ✅Reduced local tissue defenses
Reduced local defenses may prevent any counter activity against the microorganisms
infecting the wound. Absence of necrotic tissue decreases the risk of infection by
improving the blood supply. A foreign body in the wound increases the risk of infection
by acting as a port of entry for the microorganisms. An adequate blood supply is
important for preventing infection.
Which nursing actions are appropriate when removing tape from the patient's skin
during wound care? Select all that apply. ✅Loosen the ends
Pull the tape in the direction of hair growth
Use adhesive remover to loosen the tape
Appropriate nursing actions when removing tape from the patient's skin during wound
care include loosening the ends, pulling the tape in the direction of hair growth, and
using adhesive remover to loosen the tape. The application of light, not hard, traction is
appropriate for minimizing pulling of the skin. It is appropriate to gently pull the outer
end parallel, not perpendicular, to the skin surface.
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