Skin Integrity and Wound Care

1. The nurse determines that the client’s wound may be infected. To perform an aerobic wound culture, the nurse should:

1.
Collect the superficial drainage
2.
Collect the culture before cleansing the wound
3.
Obtain a culturette tube and use sterile technique
4.
Use the same technique as for collecting an anaerobic culture

ANS: 3

The nurse uses different methods of specimen collection for aerobic or anaerobic organisms.

To collect an aerobic wound culture, the nurse uses a sterile swab from a culturette tube and sterile technique. The nurse never collects a wound culture sample from old or superficial drainage. Resident colonies of bacteria from the skin grow in superficial drainage and may not be the true causative organisms of a wound infection. The nurse should clean a wound first with normal saline to remove skin flora before obtaining the culture.

DIF: A REF: 1299 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

2. Pressure ulcers form primarily as a result of:

1.
Nitrogen buildup in the underlying tissues
2.
Prolonged illness or disease
3.
Tissue ischemia
4.
Poor nutrition

ANS: 3

Pressure is the major cause of pressure ulcer formation. Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. Prolonged illness or disease and poor nutrition may place a client at risk for pressure ulcer development.

DIF: A REF: 1280 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

3. The nurse notes a client’s skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as:

1.
Stage I
2.
Stage II
3.
Stage III
4.
Stage IV

ANS: 2

This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

DIF: A REF: 1282 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

4. The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the client’s skin integrity?

1.
Having the client sit up in a chair for 4-hour intervals
2.
Keeping the head of the bed in a high-Fowler’s position to increase circulation
3.
Keeping a written schedule of turning and positioning
4.
Encouraging the client to perform pelvic muscle training exercises several times a day

ANS: 3

The frequency of repositioning should be individualized for the client; however, clients should be repositioned at least every 2 hours. The Agency for Healthcare Research and Policy (AHRQ) guidelines recommend that a written turning and positioning schedule be used. Clients able to sit in a chair should be limited to sitting for 2 hours or less. Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. Pelvic muscle training may help prevent incontinence, but it is not the best intervention for maintaining the client’s skin integrity.

DIF: A REF: 1304 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

5. Upon changing the client’s dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is:

1.
Sterile saline
2.
Hydrogen peroxide
3.
Povidone-iodine (Betadine)
4.
Sodium hypochlorite (Dakin’s solution)

ANS: 1

Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic, such as normal saline. Normal saline will not damage or kill cells, such as fibroblasts and healing tissue. Hydrogen peroxide, povidone-iodine (Betadine), and sodium hypochlorite (Dakin’s solution) are cytotoxic and therefore should not be used to clean a wound that is granulating.

DIF: A REF: 1307 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

6. A client requires wound debridement. The nurse is aware that which one of the following statements is correct regarding this procedure?

1.
It allows the healthy tissue to regenerate.
2.
When performed by autolytic means, the wound is irrigated.
3.
Mechanical methods involve direct surgical removal of the eschar layer of the wound.
4.
Enzymatic debridement may be implemented independently by the nurse whenever it is required.

ANS: 2

Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base necessary for healthy tissue to regenerate. Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. The wound is not irrigated. Mechanical methods include wet-to-dry dressings, wound irrigation, and whirlpool treatments. Surgical debridement involves direct surgical removal of the eschar layer of the wound. Enzymatic debridement requires a health care provider’s order.

DIF: A REF: 1307 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

7. The nurse prepares to irrigate the client’s wound. The primary reason for this procedure is to:

1.
Decrease scar formation
2.
Remove debris from the wound
3.
Improve circulation from the wound
4.
Decrease irritation from wound drainage

ANS: 2

The gentle washing action of the irrigation cleanses a wound of exudate and debris. The primary purpose of wound irrigation is not to improve circulation, decrease scar formation, or decrease irritation from wound drainage, but to remove debris from the wound.

DIF: A REF: 1307 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

8. When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area?

1.
Clean the area with mild soap, dry, and add a protective moisturizer.
2.
Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area.
3.
Soak the area in normal saline solution.
4.
Wash the area with an astringent and paint it with povidone-iodine (Betadine).

ANS: 1

The skin should be cleansed and completely dried and a protective moisturizer applied to keep the epidermis well lubricated. Hydrogen peroxide is cytotoxic and should not be used. A heat lamp is not necessary and would increase the client’s risk for an accidental burn. The area should not be soaked because this may lead to maceration of the skin. The area should not be cleansed with an astringent and painted with povidone-iodine. An astringent may cause excessive drying of the tissue, and povidone-iodine is cytotoxic.

DIF: A REF: 1304 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

9. A client with a large abdominal wound requires a dressing change every 4 hours. The client will be discharged to the home setting, where the dressing care will be continued. Which of the following is true concerning this client’s wound healing process?

1.
An antiseptic agent is best followed with a rinse of sterile saline solution.
2.
A heat lamp should be used every 2 hours to rid the wound area of contaminants.
3.
Sterile technique should be emphasized to the client and family.
4.
A dressing covering will allow the wound area to remain moist.

ANS: 4

A dressing should support a moist wound environment if the wound is healing by secondary intention, such as with a large abdominal wound. A moist wound base facilitates the movement of epithelialization, thus allowing the wound to resurface as quickly as possible. Only mild soap may be used or saline. Antiseptics may be damaging to granulation tissue. A heat lamp should not be used because it will dry out the wound and impair the movement of epithelialization. Clean dressings may be used in the home setting.

DIF: A REF: 1312 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

10. Upon inspection of the client’s wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select based on the wound assessment is:

1.
Foam
2.
Hydrogel
3.
Hydrocolloid
4.
Transparent film

ANS: 1

A foam dressing absorbs exudate and debris while maintaining a moist environment. Topical agents, such as antibiotic ointment, may also be used with a foam dressing. This would be the most appropriate type of dressing for this wound. A hydrogel dressing provides moisture to a clean granular wound. A hydrocolloid dressing interacts with the wound fluid to provide a moist environment. Transparent film protects from friction injury and may be left in place up to 7 days.

DIF: A REF: 1313 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

11. A client has a healing abdominal wound. The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing?

1.
Primary intention
2.
Inflammatory phase
3.
Proliferative phase
4.
Secondary intention

ANS: 3

During the proliferative phase, the wound fills with granulation tissue (including collagen formation), the wound contracts, and the wound is resurfaced by epithelialization. Primary intention is not a phase of wound healing. Wounds that heal by primary intention have minimal tissue loss, such as a surgical wound. The edges are approximated and the risk for infection is low. During the inflammatory phase, platelets gather to stop bleeding, a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris. Secondary intention is not a phase of wound healing. Wounds that heal by secondary intention have loss of tissue, such as a pressure ulcer. The wound is left open until it becomes filled by scar tissue.

DIF: A REF: 1286 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

12. A client comes to the emergency department following an injury. The nurse implements appropriate first aid for the client when:

1.
Removing any penetrating objects
2.
Elevating an affected part that is bleeding
3.
Vigorously cleaning areas of abrasion or laceration
4.
Keeping any puncture wounds from bleeding

ANS: 2

If a client is bleeding, the nurse applies direct pressure and elevates the affected part. When a penetrating object is present, it is not removed. Removal could cause massive, uncontrolled bleeding. Vigorous cleaning can cause bleeding or further injury. Abrasions and minor lacerations should be rinsed with normal saline and lightly covered with a dressing. Puncture wounds are allowed to bleed to remove dirt and other contaminants.

DIF: A REF: 1311 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

13. The nurse is concerned that the client’s midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication?

1.
Administering antibiotics to prevent infection
2.
Using appropriate sterile technique when changing the dressing
3.
Keeping sterile towels and extra dressing supplies near the client’s bed
4.
Placing a pillow over the incision site when the client is deep breathing or coughing

ANS: 4

A strategy to prevent dehiscence is to use a folded thin blanket or pillow placed over an abdominal wound when the client is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure. A client who has an infection is at risk for poor wound healing and dehiscence. However, prophylactic use of antibiotics is not the best intervention to prevent dehiscence. Using appropriate sterile technique is always important to prevent the development of infection but is not the best intervention to prevent dehiscence.

DIF: A REF: 1287 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

14. Following a head injury, the client has thin drainage coming from the left ear. The nurse describes this drainage as:

1.
Serous
2.
Purulent
3.
Cerebrospinal fluid
4.
Serosanguineous

ANS: 1

Serous drainage is clear, watery plasma. Purulent drainage is thick, yellow, green, tan, or brown. Drainage must be tested to determine if it is cerebrospinal fluid. The nurse should describe the drainage by its appearance (i.e., serous). Serosanguineous drainage is pale, red, and watery, a mixture of clear and red fluid.

DIF: A REF: 1287 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

15. Which nursing entry is most complete in describing a client’s wound?

1.
Wound appears to be healing well. Dressing dry and intact.
2.
Wound well approximated with minimal drainage.
3.
Drainage size of quarter; wound pink, 4 × 4s applied.
4.
Incisional edges approximated without redness or drainage; two 4 × 4s applied.

ANS: 4

This is the most complete description of the client’s wound. It describes the wound according to characteristics observed and the dressing that covers it. Wounds should be measured using the metric system, not described as the size of objects.

DIF: A REF: 1307 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

16. The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the client who has exposure to:

1.
Urine
2.
Purulent exudates
3.
Pancreatic fluids
4.
Serosanguineous drainage

ANS: 3

Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Exposure to urine, bile, stool, acetic fluid, and purulent wound exudates carries a moderate risk for skin breakdown. Serosanguineous drainage is not caustic to the skin, and the risk for skin breakdown from exposure to this fluid is low.

DIF: A REF: 1287 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

17. The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape:

1.
At a 45-degree angle to the skin surface while pulling away from the wound
2.
At a right angle to the skin surface while pulling toward the wound
3.
At a right angle to the skin surface while pulling away from the wound
4.
Parallel to the skin surface while pulling toward the wound

ANS: 4

To remove tape safely, the nurse loosens the tape ends and gently pulls the outer end parallel with the skin surface toward the wound. Tape should not be pulled in a direction away from the wound because this may cause the wound edges to separate. Holding the tape at a right angle to the skin surface may pull on the wound bed, causing separation of wound layers, or may damage the underlying skin.

DIF: A REF: 1320 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

18. When cleaning a wound, the nurse should:

1.
Wash over the wound twice and discard that swab
2.
Move from the outer region of the wound toward the center
3.
Start at the drainage site and move outward with circular motions
4.
Use an antiseptic solution followed by a normal saline rinse

ANS: 3

To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in circular rotations outward from a point closest to the drain. The nurse never uses the same piece of gauze or swab to cleanse across an incision or wound twice. The wound should be cleansed in a direction from the least contaminated area, such as from the wound to the surrounding skin. The wound is cleaned from the center region to the outer region. An antiseptic solution is not used to clean a wound, as it may be cytotoxic.

DIF: A REF: 1324 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

19. The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by:

1.
Filling two thirds of the wound cavity
2.
Leaving saline-soaked folded gauze squares in place
3.
Putting the dressing in very tightly
4.
Extending only to the upper edge of the wound

ANS: 4

The wound should be packed only until the packing material reaches the surface of the wound. Wound packing that overlaps onto the wound edges can cause maceration of the tissue surrounding the wound. It can also impede the proper healing and closing of the wound. The wound should be packed to the upper edge of the wound to prevent dead space and the formation of abscesses. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. The wound should not be packed too tightly. Overpacking the wound may cause pressure on the tissue in the wound bed.

DIF: A REF: 1319 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

20. The nurse is aware that application of cold is indicated for the client with:

1.
Menstrual cramping
2.
An infected wound
3.
A fractured ankle
4.
Degenerative joint disease

ANS: 3

Direct trauma such as fractures or sprains may be treated with cold. The application of cold can initially diminish swelling and pain. Application of heat to reduce muscle tension and reduce pain would be more appropriate for the client with menstrual cramping. The application of cold is not indicated for the client with an infected wound because it reduces the blood flow to the area. This would limit the number of macrophages to clear the area of bacteria and would lessen the nutrient supply to the already impaired tissue. The effects of heat application would be more beneficial to the client with degenerative joint disease.

DIF: A REF: 1335 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

21. The client has a stage IV pressure ulcer. In accordance with the Agency for Healthcare

Research and Quality (AHRQ), the nurse recommends that the client should have a(n):

1.
Foam mattress
2.
Air-fluidized bed
3.
Rotokinetic bed
4.
Static support surface

ANS: 2

Air-fluidized beds are recommended for clients with burns or multiple stage III or stage IV pressure ulcers. A foam mattress is recommended for pressure reduction in clients at high risk for developing a pressure ulcer. A Rotokinetic bed is recommended for clients who are at risk for or have developed atelectasis and/or pneumonia. A static support surface is not recommended for a client with a stage IV ulcer. It is used for clients at high risk for developing a pressure ulcer.

DIF: A REF: 1305 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

22. The nurse uses the Norton scale in the extended care facility to determine the client’s risk for pressure ulcer development. Which one of the following scores, based on this scale, places the client at the highest level of risk?

1.
6
2.
8
3.
15
4.
19

ANS: 1

According to the Norton scale, a lower score indicates a higher risk for pressure ulcer development. The total score ranges from 5 to 20. The client at highest risk would be the client with a score of 6.

DIF: A REF: 1288 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

23. The client requires support, and an abdominal binder is ordered. The nurse correctly implements the use of a binder by:

1.
Using it as a replacement for underlying dressings
2.
Keeping it loose for client comfort
3.
Having the client sit or stand when it is applied
4.
Making sure the client has adequate ventilatory capacity

ANS: 4

After applying the binder, the nurse should assess the client’s ability to ventilate properly, including deep breathing and coughing. Wounds should be entirely covered with dressings; the binder is applied over the dressing. The binder should not be loose, or it will be ineffective in providing support. The client should be lying supine with head slightly elevated and knees slightly flexed for application of the abdominal binder.