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Chapter 48: Skin Integrity And Wound Care (Skin Integrity And Wound Care - Implementation And Evaluation) –Q&A
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Chapter 48: Skin Integrity And Wound Care (Skin Integrity And Wound Care - Implementation And Evaluation) –Q&A

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  • September 21, 2024
  • 17
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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Chapter 48: Skin Integrity And Wound Care (Skin
Integrity And Wound Care - Implementation And
Evaluation) –Q&A

The nurse is managing wound care for a patient with a stage III pressure ulcer
on the elbow. The nurse cleans the area and removes all the dead, nonviable
tissue from the wound. What term is used to describe this process? Right
Ans - A. Irrigation

*B. Debridement*

C. Hemostasis

D. Cleansing

Rationale: Removal of nonviable necrotic tissue from the wound is called
debridement, which can be accomplished chemically, mechanically,
autolytically, or surgically. Debridement rids the wound of dead tissues that
are ideal for bacterial growth and minimizes the risk of infection. Irrigation
involves cleaning the wound with a cleaning solution under pressure to
remove bacteria and exudates from the wound bed and maintain moisture.
Hemostasis is the control of bleeding from a wound. Cleansing is not used to
describe the removal process of dead tissue from the wound.

Pg. 1206-1207

Which nursing intervention is appropriate for a patient who is at risk for skin
breakdown due to poor dietary intake? Right Ans - A. Keep the skin dry and
free of maceration

B. Provide pressure-redistribution surface

*C. Consult a dietician for nutritional assessment*

D. Provide a trapeze to facilitate movement in bed

Rationale: Whereas all of these interventions are appropriate for a patient
who is at risk for skin breakdown, the the one specific to a patient at risk for

,skin breakdown due to poor dietary intake is to consult a dietician for a
nutritional assessment. Keeping the skin dry and free of maceration is
appropriate for a patient who is at risk for skin breakdown due to moisture.
Providing a pressure-redistribution surface is appropriate for a patient who is
at risk for skin breakdown due to decreased sensory perception. Providing a
trapeze to facilitate movement in bed is appropriate for a patient who is at
risk for skin breakdown due to friction and shear.

Pg. 1206

Which is the most effective intervention for compromised skin integrity?
Right Ans - *A. Preventing breakdown*

B. Administering medication

C. Implementing wound care

D. Monitoring wound healing

Rationale: The most effective intervention for compromised skin integrity and
wound care is prevention of skin breakdown. Whereas administering
medication, implementing wound care, and monitoring wound healing are all
important nursing actions, prevention is the first step.

Pg. 1205

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? Right Ans - A. Accelerated wound healing

B. Need for advancing the drain

C. Dislodged tube of the drain

*D. Blockage in the drainage tube*

Rationale: 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.

Pg. 1199

A patient with multiple fractures has casts that make it difficult to move
voluntarily. The nurse notices red skin in the spinal area that blanches on
applying pressure. What measures does the nurse take to decrease the risk of
development of pressure ulcers in this patient? Select all that apply. Right
Ans - A. Position the patient in the most comfortable position and do not
move.

B. Cover the hyperemic skin area with a sterile dressing and apply antiseptics.

*C. Check the skin around the casts regularly for any signs of deteriorated skin
condition.*

*D. Take care to avoid friction injuries during repositioning, bathing, or
transferring of the patient.*

*E. Use good hygiene techniques to ensure the patient's skin is clean and dry
after bowel movements.*

Rationale: When the nurse suspects a developing pressure ulcer, other areas
should be checked for deteriorated skin condition, especially around casts. It
helps in early detection and prompt treatment. The nurse should ensure that
the skin of the patient is clean and dry and not overly moistened for prolonged
periods. Excess moisture increases the risk of pressure ulcers. When
repositioning, bathing, or transferring the patient, care should be taken to
avoid friction injuries to the affected area or other areas. The patient should
be repositioned at regular intervals to relieve pressure and avoid pressure
being exerted on one or the same body parts constantly. The area of
hyperemic skin should not be covered, but inspected at regular intervals for
abnormal hyperemia, induration, or nonblanching.

Pg. 1187, 1196

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