Introduction to Skin Integrity and Basic Wound Care
Total Questions : 9
Showing 9 questions, Sign in for moreA nurse is assessing a client with a pressure ulcer on the sacrum. Which of the following factors would increase the risk of infection in the wound?
Explanation
Answer: A.
The presence of necrotic tissue increases the risk of infection by providing a medium for bacterial growth and impairing wound healing. Necrotic tissue should be debrided to promote wound healing.
B. The use of hydrocolloid dressing is not a risk factor for infection. Hydrocolloid dressings are occlusive and adhesive, which create a moist environment that facilitates wound healing and prevents bacterial contamination.
C. The frequency of wound irrigation is not a risk factor for infection. Wound irrigation is done to cleanse the wound and remove debris and exudate. It should be done gently and with sterile solution to avoid trauma and contamination.
D. The application of topical antibiotics is not a risk factor for infection. Topical antibiotics are used to treat or prevent infection in some wounds. They should be used with caution and as prescribed, as overuse may lead to resistance or allergic reactions.
A client is admitted with a burn injury that involves the epidermis and part of the dermis. The nurse knows that this type of burn is classified as:
Explanation
Answer: B
Partial-thickness burn is a burn that involves the epidermis and part of the dermis. It causes blisters, pain, and redness. It may heal spontaneously or require skin grafting depending on the depth and extent of the injury.
A. Superficial burn is a burn that involves only the epidermis. It causes erythema, mild pain, and no blisters. It heals within a few days without scarring.
C. Full-thickness burn is a burn that involves the epidermis, dermis, and underlying tissues such as fat, muscle, or bone. It causes charred, white, or black skin, no pain, and loss of sensation. It requires skin grafting and may result in scarring and contractures.
D. Deep partial-thickness burn is a burn that involves the epidermis and most of the dermis. It causes white or red skin, severe pain, and decreased sensation. It may heal slowly or require skin grafting.
A nurse is caring for a client who has a surgical incision with sutures. The nurse observes that the edges of the wound are well approximated and there is minimal drainage from the site. The nurse documents this type of wound healing as:
Explanation
Answer: A
Primary intention is a type of wound healing that occurs when the edges of the wound are well approximated and there is minimal tissue loss or infection. It results in minimal scarring and fast healing.
B. Secondary intention is a type of wound healing that occurs when the edges of the wound are not approximated or there is extensive tissue loss or infection. It results in granulation tissue formation, contraction, and epithelialization. It takes longer to heal and may result in scarring and infection.
C. Tertiary intention is a type of wound healing that occurs when there is a delay in closing the wound or when the wound is intentionally left open for drainage or debridement. It results in less scarring than secondary intention but more than primary intention.
D. Quaternary intention is not a valid term for wound healing.
A client has a wound on the lower leg that is covered with dry, yellow crusts. The nurse recognizes this as an indication of:
Explanation
Answer: A.
Slough is dead tissue that is shed from the surface of the wound. It may be white, yellow, green, or brown in color and may have a soft, moist, or dry texture. It should be removed to promote wound healing.
B. Eschar is dead tissue that adheres to the surface of the wound. It may be black, brown, or tan in color and may have a hard, dry, or leathery texture. It may act as a natural barrier to infection in some cases, but it may also impair wound healing and circulation in others.
C. Granulation tissue is new tissue that forms in the base of the wound during healing. It is red or pink in color and has a shiny, moist, granular appearance. It indicates healthy wound healing and should be protected from trauma or infection.
D. Epithelial tissue is new tissue that forms over the granulation tissue during healing. It is pink or pale in color and has a thin, smooth, translucent appearance. It indicates the final stage of wound healing and should be moisturized and protected from sun exposure.
A nurse is applying a dressing to a wound that has moderate to heavy exudate. Which of the following types of dressing would be most appropriate for this wound?
Explanation
Answer: D
Alginate dressing is a type of dressing that is made from seaweed fibers and is highly absorbent. It is suitable for wounds that have moderate to heavy exudate, as it can absorb up to 20 times its weight in fluid. It also forms a gel-like substance when in contact with wound fluid, which creates a moist environment that facilitates wound healing and autolytic debridement.
C. Foam dressing is a type of dressing that is made from polyurethane or silicone and is moderately absorbent. It is suitable for wounds that have light to moderate exudate, as it can absorb up to four times its weight in fluid. It also provides cushioning and insulation for the wound, and prevents bacterial contamination.
B. Hydrogel dressing is a type of dressing that is made from water or glycerin and is minimally absorbent. It is suitable for wounds that have minimal exudate, as it can only absorb up to 10% of its weight in fluid. It also provides hydration and cooling for the wound, and promotes autolytic debridement and granulation tissue formation.
A. Transparent film dressing is a type of dressing that is made from polyurethane and is non-absorbent. It is suitable for wounds that have no exudate, as it does not absorb any fluid. It also provides protection and visualization for the wound, and allows gas exchange and moisture vapor transmission.
A nurse is evaluating the effectiveness of negative pressure wound therapy (NPWT) on a client with a chronic wound. Which of the following outcomes would indicate that the therapy is successful?
Explanation
Answer: B
The wound has decreased in drainage is an outcome that would indicate that NPWT is successful. NPWT is a type of therapy that uses a vacuum device to apply negative pressure to the wound, which removes excess fluid, debris, and infectious material from the wound bed. This reduces edema, inflammation, and bacterial load, and promotes blood flow, oxygenation, and granulation tissue formation.
A. The wound has increased in size is an outcome that would indicate that NPWT is unsuccessful or harmful. NPWT should not cause wound enlargement, as this may indicate tissue damage, infection, or poor healing.
C. The wound has increased in pain is an outcome that would indicate that NPWT is unsuccessful or harmful. NPWT should not cause excessive pain, as this may indicate tissue damage, infection, or poor healing.
D. The wound has decreased in granulation tissue is an outcome that would indicate that NPWT is unsuccessful or harmful. NPWT should promote granulation tissue formation, as this indicates healthy wound healing.
A client has a venous ulcer on the lower leg that is treated with compression therapy. The nurse instructs the client to elevate the leg above the level of the heart whenever possible. What is the rationale for this instruction?
Explanation
Answer: A
To reduce edema and venous pressure is the rationale for elevating the leg above the level of the heart whenever possible. Venous ulcers are caused by chronic venous insufficiency, which impairs venous return and causes blood pooling, increased venous pressure, and edema in the lower extremities. Elevation helps to facilitate venous return and reduce edema and venous pressure, which improves wound healing.
B. To increase arterial blood flow and oxygenation is not the rationale for elevating the leg above the level of the heart whenever possible. Arterial ulcers are caused by arterial insufficiency, which impairs arterial blood flow and oxygenation to the lower extremities. Elevation may worsen arterial blood flow and oxygenation, as it reduces the effect of gravity on arterial perfusion.
C. To prevent infection and inflammation is not the rationale for elevating the leg above the level of the heart whenever possible. Infection and inflammation are complications of venous ulcers, but they are not directly affected by elevation. Infection and inflammation are prevented by proper wound care, such as cleansing, dressing, debridement, and antibiotic therapy.
D. To stimulate nerve regeneration and sensation doesn’t help with venous ulcers.
client with a burn wound on the chest has a silver sulfadiazine (Silvadene) cream applied to the wound. Which adverse reaction should the nurse monitor for in this client?
Explanation
Correct answer: D) A and B.
Rationale: Silver sulfadiazine (Silvadene) is a topical antimicrobial agent used to prevent or treat infection in burn wounds. The nurse should monitor for hypersensitivity or allergic reaction, such as rash, itching, swelling, or difficulty breathing; and leukopenia or decreased white blood cell count, which can increase the risk of infection. The nurse should obtain a baseline complete blood count (CBC) before applying the cream and repeat it every few days during treatment.
Incorrect option:
C) Hyperglycemia or increased blood glucose level. - This is not a common adverse reaction of silver sulfadiazine (Silvadene). However, the client with a burn wound may have hyperglycemia due to stress, inflammation, or infection. The nurse should monitor the blood glucose level regularly and administer insulin as prescribed.
A client with a surgical wound on the abdomen has a negative pressure wound therapy (NPWT) device attached to the wound. Which action should the nurse take when caring for this client?
Explanation
Correct answer: C) Ensure that the dressing is sealed and airtight around the wound.
Rationale: Negative pressure wound therapy (NPWT) is a device that applies
subatmospheric pressure to the wound bed, which promotes granulation tissue formation, removes excess fluid and debris, and reduces edema and bacterial colonization. The nurse should ensure that the dressing is sealed and airtight around the wound to maintain negative pressure and prevent air leaks.
Incorrect options:
A) Change the dressing every 12 hours or as needed. - This is not recommended for NPWT, as frequent dressing changes can disrupt wound healing and increase the risk of infection. The nurse should change the dressing every 48 to 72 hours or as prescribed by the provider.
B) Irrigate the wound with normal saline before applying the dressing. - This is not recommended for NPWT, as irrigation can introduce bacteria into the wound and interfere with negative pressure. The nurse should clean the wound with normal saline or sterile water and pat it dry gently before applying the dressing.
D) Clamp the tubing when ambulating or repositioning the client. - This is not recommended for NPWT, as clamping can interrupt negative pressure and cause tissue damage. The nurse should secure the tubing to prevent kinking or dislodgment and keep the device below the level of the wound when ambulating or repositioning the client.
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