Chapter 48: Skin Integrity and Wound Care (Skin Integrity and Wound Care - Implementation and Evaluation) Questions With Solutions
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Course
WOCN
Institution
WOCN
Chapter 48: Skin Integrity and Wound Care
(Skin Integrity and Wound Care -
Implementation and Evaluation) Questions
With Solutions
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 tissu...
Chapter 48: Skin Integrity and Wound Care
(Skin Integrity and Wound Care -
Implementation and Evaluation) Questions
With Solutions
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? 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.
, Chapter 48: Skin Integrity and Wound Care
(Skin Integrity and Wound Care -
Implementation and Evaluation) Questions
With Solutions
Pg. 1206-1207
Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to
poor dietary intake? 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
, Chapter 48: Skin Integrity and Wound Care
(Skin Integrity and Wound Care -
Implementation and Evaluation) Questions
With Solutions
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? *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.
, Chapter 48: Skin Integrity and Wound Care
(Skin Integrity and Wound Care -
Implementation and Evaluation) Questions
With Solutions
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? 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
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