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Fundamentals of Nursing Chapter 48_ Skin Integrity and Wound Care Practice questions ( CA$11.72
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Fundamentals of Nursing Chapter 48_ Skin Integrity and Wound Care Practice questions (

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Fundamentals of Nursing Chapter 48_ Skin Integrity and Wound Care Practice questions (

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  • August 6, 2024
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  • 2024/2025
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Fundamentals of Nursing Chapter 48: Skin Integrity
and Wound Care Practice questions
ANS: B
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 a diet low in calories and fat are not included
among the predisposing factors. - ANS-1. The nurse is working on a medical-surgical unit that
has been participating in a research project associated with pressure ulcers. The nurse
recognizes that the risk factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.

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: B
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. - ANS-3. Which nursing
observation would indicate that the patient was at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds.

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." Once an ulcer has been staged, the stage
endures even as the ulcer heals. This ulcer was labeled a stage III, 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. - ANS-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 would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer

ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss
involving epidermis, dermis, or both. The ulcer is superficial and 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. - ANS-5. The nurse is admitting an older patient from a nursing home.
During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of
the patient. This pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV.

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 whole 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 not the first item used. - ANS-6. The nurse is

, completing a skin assessment on a patient with darkly pigmented skin. Which of the following
would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light

ANS: C
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 three phases: inflammatory, proliferative, and remodeling. 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 approximated. Wound closure is delayed until risk of infection is
resolved. - ANS-7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse
recalls that a pressure ulcer takes time to heal and is an example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.

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: C
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which
indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a
substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is
called eschar, which also needs to be removed for a wound to heal. Purulent drainage is
indicative of an infection and will need to be resolved for the wound to heal. - ANS-9. The nurse

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