Skin Integrity and Wound Care Essay

Skin Integrity and Wound Care

1. When repositioning an immobile patient, the nurse notices
redness over a bony prominence. What is indicated when a
reddened area blanches on fingertip touch?
1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage III pressure ulcer needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body
to overcome the ischemic episode.
2. Which type of pressure ulcer is noted to have intact skin and
may include changes in one or more of the following: skin
temperature (warmth or coolness), tissue consistency (firm or
soft), and/or pain?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
3. When obtaining a wound culture to determine the presence
of a wound infection, from where should the specimen be
taken?
1. Necrotic tissue
2. Wound drainage
3. Drainage on the dressing
4. Wound after it has first been cleaned with normal saline
4. After surgery the patient with a closed abdominal wound
reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces
of small bowel are noted at the bottom of the now-opened
wound. Which corrective intervention should the nurse do
first?
1. Allow the area to be exposed to air until all drainage has
stopped
2. Place several cold packs over the area, protecting the skin
around the wound

3. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a
wound evisceration
4. Cover the area with sterile gauze, place a tight binder over
it, and ask the patient to remain in bed for 30 minutes
because this is a minor opening in the surgical wound and
should reseal quickly
5. Which description best fits that of serous drainage from a
wound?
1. Fresh bleeding
2. Thick and yellow
3. Clear, watery plasma
4. Beige to brown and foul smelling
6. 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?
1. Binder
2. Ice bag
3. Elastic bandage
4. Absorptive diaper

Skin Integrity and Wound Care Essay

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