Exam (elaborations)

Practice Test Questions Chapter 36; Skin Integrity & Wound Care with Correct Answers

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Skin Integrity and wound care

Institution
Skin Integrity And Wound Care

Practice Test Questions Chapter 36; Skin Integrity & Wound Care with Correct Answers Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is a...

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Uploaded on September 18, 2024
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practice test questions chapter 36 skin integrity

Institution Skin Integrity and wound care
Course Skin Integrity and wound care

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TITLE: EMILLYCHARLOTTE 2024/2025 ACADEMIC PERIOD
OWNER: EMILLYCHARLOTTE
COPYRIGHT STATEMENT: ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED
FIRST PUBLISHED: SEPTEMBER 2024

Practice Test Questions Chapter 36;
Skin Integrity & Wound Care with
Correct Answers

Your client has a Braden scale score of 17. Which is the most appropriate nursing

action?

1. Assess the client again in 24h; the score is within normal limits.

2. Implement a turning schedule; the client is at increased risk for skin breakdown.

3. Apply a transparent wound barrier to major pressure sites; the client is at moderate

risk for skin breakdown.

4. Request an order for a special low-air-loss bed; the client is at very high risk for skin

breakdown. - Answer✔️✔️-2. Implement a turning schedule; the client is at increased risk

for skin breakdown; A score ranging from 15 to 18 is considered at risk and a turning

schedule is appropriate.

Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option

3, moderate risk, for which a transparent barrier would be appropriate, is applied to

persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a

score of 9 or less.

Proper technique for performing a wound culture includes what?

,TITLE: EMILLYCHARLOTTE 2024/2025 ACADEMIC PERIOD
OWNER: EMILLYCHARLOTTE
COPYRIGHT STATEMENT: ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED
FIRST PUBLISHED: SEPTEMBER 2024

1. Cleansing the wound prior to obtaining the specimen.

2. Swabbing for the specimen in the area with the largest collection of drainage.

3. Removing crusts or scabs with sterile forceps and then culturing the site beneath.

4. Waiting 8 hours following a dose of antibiotic to obtain the specimen. - Answer✔️✔️-1.

Cleansing the wound prior to obtaining the specimen; Wound culture specimens should

be obtained from a cleaned area of the wound. Microbes responsible for infection are

more likely to be found in viable tissue.

Collected drainage contains old and mixed organisms. An appropriate specimen can be

obtained without causing the client the discomfort of debriding. The nurse does not

generally debride a wound to obtain a specimen. Once systemic antibiotics have been

begun, the interval following a does will not significantly affect the concentration of

wound organisms.

Which of the following items are used to perform wound care irrigation? Select all that

apply.

1. Clean gloves

2. Sterile gloves

3. Refrigerated irrigating solution

4. 60-mL syringe - Answer✔️✔️-1, 2, and 4; To irrigate a wound, the nurse uses clean

gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus

, TITLE: EMILLYCHARLOTTE 2024/2025 ACADEMIC PERIOD
OWNER: EMILLYCHARLOTTE
COPYRIGHT STATEMENT: ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED
FIRST PUBLISHED: SEPTEMBER 2024
sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the

volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid

should be at room or body temperature-- certainly not refrigerated.

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no

necrotic areas. The nurse would treat the area with which dressing?

1. Alginate

2. Dry Gauze

3. Hydrocolloid

4. No dressing indicated. - Answer✔️✔️-3. Hydrocolloid; Hydrocolloid dressings protect

shallow ulcers and maintain an appropriate healing environment.

Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2)

will stick to granulation tissue, causing more damage. A dressing is needed to protect

the wound and enhance healing.

Which of the following are primary risk factors for pressure ulcers? Select all that apply.

1. Low-protein diet

2. Insomnia

3. Lengthy surgical procedures

4. Fever

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Exam (elaborations)

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