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NURS 309 - Chapter 48 Skin Integrity and Wound Care Questions With Complete Solutions
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NURS 309 - Chapter 48 Skin Integrity and Wound Care Questions With Complete Solutions
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NURS 309 - Chapter 48 Skin Integrity and Wound CareQuestions With Complete Solutions
A patient has come to the clinic after sustaining an abrasion.
Which characteristic of this wound type would the nurse likely
find upon assessment? Select all that apply. One, some, or all
responses may be correct.
Superficial
Considered a partial-thickness wound
Weepy
Bleeds profusely
Associated with the risk of internal bleeding and infection
Correct Answers Superficial
Considered a partial-thickness wound
Weepy
A patient's wound drainage appears thick and yellow. Which
type of drainage is this considered?
Serous
Purulent
Sanguineous
Serosanguineous Correct Answers Purulent
After a surgical procedure, the patient experiences
thrombocytopenia. For which condition would this postsurgical
patient be at risk?
Infection
Dehiscence
,Evisceration
Hemorrhage Correct Answers Hemorrhage
After asking for the patient's level of comfort using a scale of 0
to 10, how would the nurse order the steps in assessing the
patient's pressure injury? Correct Answers Correct1.Determine
if the patient has any allergies to topical agents.
Correct2.Review the order for topical agents or dressing and
location.
Correct3.Describe the procedure to the patient, and remove the
dressing.
Correct4.Note the color and percentage of tissue type present in
the wound base.
Correct5.Measure the width and length of the injury.
Correct6.Measure the depth of undermining by using a cotton-
tipped applicator.
Correct7.Inspect the periwound skin, checking for maceration,
redness, or any denuded areas.
Correct8.Remove gloves and perform hand hygiene.
Correct9.Review the medical record to assess for any significant
weight loss.
For a patient who has a muscle sprain, localized hemorrhage, or
hematoma, which wound care product helps prevent edema
formation, control bleeding, and anesthetize the body part?
Binder
Ice bag
Elastic bandage
Absorptive diaper Correct Answers Ice bag
, An ice bag helps constrict excess fluid in tissues, which prevents
edema. The blood vessels become constricted, help control
bleeding, and can decrease pain where the ice bag is placed.
Binders are usually placed around the abdomen to make
movement less painful and to provide support. Elastic bandages
promote hemostasis and will not help anesthetize the body part.
An absorptive diaper is not appropriate in this situation.
How far beyond the wound edges would the nurse extend the
sealant when framing the periwound area of a patient?
1 to 2 cm (0.4 to 0.8 inch)
2 to 4 cm (0.8 to 1.6 inches)
2.5 to 5 cm (1 to 2 inches)
4 to 6 cm (1.6 to 2.4 inches) Correct Answers 2.5 to 5 cm (1 to
2 inches)
Extending the sealant 2.5 to 5 cm (1 to 2 inches) beyond the
wound edges is an accurate nursing action when framing the
periwound area with skin sealant. Extending it to 1 to 2 cm (0.4
to 0.8 inch) or 2 to 4 cm (0.8 to 1.6 inches) is not enough.
Extending it to 4 to 6 cm (1.6 to 2.4 inches) is more than
necessary.
How is the nursing care for a patient who has a stage 4 pressure
injury different from that for a patient who has a stage 1 pressure
injury?
Stage 4 requires keeping the patient out of a slouched position.
Stage 4 requires the use of a low-air-loss, alternating pressure, or
air-fluidized support surface.
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