Factors affecting skin integrity
1.
The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. There is a notation that states there is an absence of the stratum corneum. Which of the following explains why this is a concern?
1. The stratum corneum provides insulation for temperature regulation.
2. The stratum corneum promotes strength and elasticity to the skin.
3. The stratum corneum protects the body against the entry of pathogens.
4. The stratum corneum produces new skin cells on a continuing basis.
Feedback
1. This is incorrect. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose).
2. This is incorrect. The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin.
3. This is correct. The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals.
4. This is incorrect. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface.
p. 918 (v1)
35.
The nurse in the emergency department admits a client with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing?
1. Serous
2. Sanguineous
3. Purosanguineous
4. Purulent
Feedback
1. This is incorrect. Serous drainage is clear, faintly yellow drainage. Serous drainage occurs when there is inflammation, such as with a burn injury.
2. This is correct. Sanguineous drainage contains blood, which would be expected from a wound with active bleeding.
3. This is incorrect. Purosanguineous fluid contains pus, which occurs with infection. This client has a wound from an acute injury. Although infection risk is high with gunshot wounds, infection generally takes 2 or more days to occur.
4. This is incorrect. Purulent drainage indicates infection. This wound is too recent to demonstrate infection.
p. 926
11.
The nurse recognizes that pressure ulcers are directly caused by which of the following conditions at the site?
1. Ischemia
2. Edema
3. Shearing forces
4. Vascular issues
Feedback
1. This is correct. Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue.
2. This is incorrect. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.
3. This is incorrect. Although friction and shear are extrinsic factors affecting skin integrity and increase the risk of pressure ulcers, they are not the direct cause.
4. This is incorrect. Inadequate arterial blood flow to an area as a result of pressure causes the development of a pressure ulcer.
p. 935
27.
The nurse is preparing to apply heat therapy alternated with cold therapy to a wound. What is the proper method for this therapy?
1. Leave the therapy on each area no longer than 15 minutes.
2. Leave the therapy on each area no longer than 30 minutes.
3. When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it.
4. When using cold, ensure the temperature is less than 32°F (0°C) before applying it.
Feedback
1. This is correct. Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy more effective by preventing rebound phenomenon.
2. This is incorrect. Leaving the heat or cold therapies on longer than 15 minutes could cause tissue damage.
3. This is incorrect. Temperatures should be kept between 59°F and 113°F (15°C and 45°C), depending on the type of therapy chosen and what is comfortable to the client. Temperatures colder or hotter than those recommended can damage tissue.
4. This is incorrect. Temperatures should be kept between 59°F and 113°F (15°C and 45°C), depending on the type of therapy chosen and what is comfortable to the client. Temperatures colder or hotter than those recommended can damage tissue.
p. 922
24.
The nurse is preparing to provide wound care to a client with many open wounds. Which of the following actions would be the most appropriate method for dressing changes of multiple open wounds that require treatment?
1. Remove all of the soiled dressings before beginning wound treatment.
2. Cleanse wounds from the most contaminated area to the least contaminated area.
3. Treat wounds on the client’s side first and then the front and back of the client.
4. Irrigate wounds from the least contaminated area to the most contaminated area.
Feedback
1. This is incorrect. This would leave all of the wounds open to contamination during a dressing change.
2. This is incorrect. The proper method would be to proceed from “clean” to “dirty” areas, to avoid cross contamination.
3. This is incorrect. There is not enough information to describe the placement of the wounds.
4. This is correct. To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.
p. 938 (V1)
2.
The nurse understands that the client who takes antihypertensive medications is at risk for compromised skin integrity and poor wound healing. What is the rationale for that understanding?
1. Antihypertensives can cause cellular toxicity.
2. Antihypertensives increase the risk of ischemia.
3. Antihypertensives can delay wound healing.
4. Antihypertensives predispose to hematoma formation.
Feedback
1. This is incorrect. Chemotherapeutic agents delay wound healing because of their cellular toxicity.
2. This is correct. Antihypertensive medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia.
3. This is incorrect. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury.
4. This is incorrect. Antihypertensives do not increase the clotting factor.
p. 918 (v1)
38.
The client has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound?
1. Pressure ulcer
2. Venous stasis ulcer
3. Diabetic foot ulcer
4. Arterial ulcer
Feedback
1. This is incorrect. A pressure ulcer is unlikely to develop on the medial side of the calf because it is neither a bony area nor one that is likely to be an area where there is pressure.
2. This is correct. The location of the ulcers and the history of past deep vein thrombosis would make venous stasis ulcers the most likely classification for these wounds. They occur usually between the inside ankle and the knee, not necessarily over a bony prominence, and are typically red in color, shiny, and taut, and may even feel warm or hot. Fluid drainage can be significant.
3. This is incorrect. There is no indication that this client is diabetic, and the wound is not on the foot. An arterial (ischemic) ulcer tends to be dry and pale, with little drainage. Arterial ulcers are usually very painful, especially at night.
4. This is incorrect. An arterial (ischemic) ulcer tends to be dry and pale, with little drainage. Arterial ulcers are usually very painful, especially at night.
p. 922 (v1)
36.
An adult client is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The client has no problem with rubbing, friction, or shear. What is the Braden score for this client?
1. 10
2. 15
3. 20
4. 23
Feedback
1. This is incorrect. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the client’s risk: the lower the score, the more likely it is the client will develop a pressure ulcer.
2. This incorrect. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the client’s risk: the lower the score, the more likely it is the client will develop a pressure ulcer.
3. This is incorrect. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the client’s risk: the lower the score, the more likely it is the client will develop a pressure ulcer.
4. This is correct. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the client’s risk: the lower the score, the more likely it is the client will develop a pressure ulcer. The client receives 4 points for sensory perception, moisture, activity, mobility, and nutrition and 3 points for friction and shear, making a total of 23 points, which is a perfect score.
p. 752 (v2)
34.
The nurse is providing care to the client that has experienced extensive third-degree burns. The nurse is aware that this client will have what type of healing?
1. Primary intention
2. Secondary intention
3. Tertiary intention
4. Primary intention if no infection occurs
Feedback
1. This is incorrect. Wound healing by primary intention occurs when there is minimal or no tissue loss, and edges are well approximated. With a third-degree burn the edges cannot approximate for primary intention healing.
2. This is incorrect. Secondary intention healing occurs when a wound (1) involves extensive tissue loss, which prevents wound edges from approximating (coming together), or (2) should not be closed (e.g., because it is infected). Because the wound is left open, it heals from the inner layer to the surface by filling in with beefy red granulation tissue (a form of connective tissue with an abundant blood supply)
3. This is correct. A third-degree burn heals by tertiary intention. Skin grafts would be required to bring edges of granulation tissue together.
4. This is incorrect. Wound healing by primary intention occurs when there is minimal or no tissue loss, and edges are well approximated. With a third-degree burn the edges cannot approximate for primary intention healing. Even if no infection occurs, this wound will not heal by primary intention because of deep tissue loss.
p. 924
9.
The nurse is reviewing the client’s surgical report and notes that the client has a history of evisceration. The nurse researches the differences between dehiscence and evisceration. Which of the following describes the difference between dehiscence and evisceration?
1. Dehiscence involves a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.
2. Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent.
3. Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue.
4. Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.
Feedback
1. This is correct. With dehiscence, there is separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incision site.
2. This is incorrect. Evisceration is an urgent complication usually requiring immediate surgical intervention.
3. This is incorrect. Evisceration is the protrusion of internal viscera from an incisional site, dehiscence is the separation of the surgical wound.
4. This is incorrect. Evisceration can damage internal organs, while dehiscence can damage dermal tissue.
p. 927 (V1)
16.
The nurse obtains a swab culture from a chronic wound and understands that this may have limited findings. Why is the information obtained from a swab culture of a wound limited?
1. A positive culture does not necessarily indicate infection because chronic wounds are often colonized by bacteria.
2. A negative culture may not indicate infection because chronic wounds are often colonized by bacteria.
3. Most wound infections are viral, so the swab culture would not be indicative of an infection.
4. A swab culture result does not include bacterial sensitivity information necessary to provide treatment.
Feedback
1. This is correct. The information obtained from a swab culture is limited because a positive culture may not indicate infection. A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse. However, the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider.
2. This is incorrect. Chronic wounds are often colonized by bacteria, but this does not require antibiotic treatment.
3. This is incorrect. Most wound infections are bacterial, not viral.
4. This is incorrect. Swab specimens have been shown to be accurate in representing bacteria counts biopsied from a wound.
p. 918 (V1)
33.
The nurse assesses the surrounding skin of the client’s colostomy. The client has been incorrectly applying his ostomy appliance and which caused a wound due to the continuous contact with liquid stool. The nurse notes bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound?
1. Acute, full-thickness, open
2. Chronic, partial-thickness, closed
3. Acute, partial-thickness, closed
4. Chronic, unstageable, open
Feedback
1. This is correct. The wound is acute because it developed recently. The wound is full-thickness because it involves the dermis.
2. This is incorrect. The wound is open because it was bleeding, so the skin must be broken. The wound is contaminated because it is exposed to stool and appears to be infected.
3. This is incorrect. The wound is open and full thickness due to involvement of the dermis.
4. This is incorrect. This is a new wound, not chronic, and stageable as it involves the dermis.
30.
Which of the following clients does the nurse recognize as being at greatest risk for pressure ulcers?
1. An infant with skin excoriations in the diaper region
2. A young adult with diabetes in skeletal traction
3. A middle-aged adult with quadriplegia
4. An older adult requiring use of assistive device for ambulation
Feedback
1. This is incorrect. The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore.
2. This is incorrect. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore. This client is likely to shift weight in bed and respond to discomfort of pressure on a bony site.
3. This is correct. The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia).
4. This is incorrect. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal.
p. 752
39.
While applying a wet-to-dry dressing, how would the nurse explain to the client how this procedure works for promoting healing? A wet-to-dry dressing is a:
1. Method of submerging the wound in water, allowing it to soak before drying the wound bed
2. Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed
3. Means of debriding the wound but also removing granulation tissue from the wound
4. Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue
Feedback
1. This is incorrect. Hydrotherapy or whirlpool treatments are nonselective debridement wherein the wound is submerged in a whirlpool containing tepid water for a prescribed amount of time (usually 5 to 15 minutes). This form of debridement is reserved for wounds with a large amount of nonviable tissue, such as burns.
2. This is incorrect. Enzymatic debridement uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound. To use an enzymatic product, clean the wound with normal saline, apply a thin layer of the cream, and cover with a moisture-retaining dressing.
3. This is correct. A wet-to-dry dressing uses coarse gauze moistened with normal saline that is packed into the wound, allowed to dry, and then removed, perhaps several times a day. This form of nonselective debridement removes not only debris but also granulation tissue from the wound. It is also quite painful.
4. This is incorrect. Autolysis breaks down necrotic tissue by using an occlusive, moisture-retaining dressing (e.g., transparent dressing) and the body’s own enzymes and defense mechanisms. This process takes more time than the other techniques, but it is better tolerated.
p. 945 (v1)
29.
The nurse is reviewing a wound care nurse’s narrative note that states there is a fistula in the lower abdominal wall as a result of a poorly healing surgical wound. What is a common cause of a fistula?
1. Ischemic pressure to a bony prominence
2. Diminished venous return to the site
3. Abscess formation from infection or debris
4. Abnormal straining over the incisional site
Feedback
1. This is incorrect. This describes the etiology of a pressure ulcer.
2. This is incorrect. This describes the etiology of a venous stasis ulcer, not a fistula.
3. This is correct. A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Fistulas often result from infection or debris left in the wound. An abscess forms, which breaks down surrounding tissue and creates the abnormal passageway. Chronic drainage from the fistula may lead to skin breakdown and delayed wound healing. The most common sites of fistula formation are the gastrointestinal and genitourinary tracts.
4. This is incorrect. This describes a wound dehiscence. The client may cough or strain and feel a “pop” followed by an opening forming in the incision.
p. 927
32.
The nurse assesses assigned clients and determines which client is at highest risk for altered skin integrity?
1. A young adult in traction who has a low-protein diet and dehydration
2. An older client diagnosed with well-controlled type 2 diabetes
3. A middle-aged adult with metabolic syndrome taking antihypertensives
4. An adolescent in bed with influenza, having periods of high fever and diaphoresis
Feedback
1. This is correct. The young adult client in traction has multiple risk factors, including immobility, dehydration, and inadequate protein intake. Healthy skin depends on adequate protein levels to maintain the skin, repair minor defects, and preserve intravascular volume. Therefore, this client is at greatest risk for altered skin integrity.
2. This is incorrect. An elderly client with well-controlled diabetes has only one risk factor, and therefore is not at highest risk among the group of clients in the scenario.
3. This is incorrect. The middle-aged adult with metabolic syndrome, which involves obesity, hyperlipidemia, and hypertension, has compromised health, although not necessarily compromised skin integrity—unless the client were immobile, which he is not.
4. This is incorrect. Although fever and skin moisture can compromise skin integrity, the adolescent’s condition is likely transient.
p. 939
28.
The nurse is preparing to provide care to the client who has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound “heals a little more” he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing?
1. Primary intention
2. Regenerative healing
3. Secondary intention
4. Tertiary intention
Feedback
1. This is incorrect. Primary intention healing occurs when a wound involves minimal or no tissue loss and has edges that are well approximated (closed). Little scarring is expected. A clean surgical incision heals by this method. Even so, a scar is only 80% as strong as the original tissue.
2. This is incorrect. Regenerative/epithelial healing occurs when a wound affects only the epidermis and dermis. No scar forms and the new (regenerated) epithelial and dermal cells form new skin that cannot be distinguished from the intact skin. Partial-thickness wounds heal by regeneration.
3. This is incorrect. Secondary intention healing occurs when a wound (1) involves extensive tissue loss, which prevents wound edges from approximating (coming together), or (2) should not be closed (e.g., because it is infected). Because the wound is left open, it heals from the inner layer to the surface by filling in with beefy red granulation tissue (a form of connective tissue with an abundant blood supply). Epithelial tissue may appear in the wound as small pink or pearl-like areas.
4. This is correct. Tertiary intention is used when a wound is clean-contaminated or “dirty” (potentially infected). Initially, the wound can heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together, and the wound edges are sutured closed.
p. 924 (V1)
21.
Which of the following would be the most appropriate outcome for the client with a stage 2 pressure ulcer?
1. The ulcer is completely healed with minimal scarring.
2. The client reports no pain at the site.
3. A minimal amount of drainage is noted.
4. The wound bed contains 100% granulated tissue.
Feedback
1. This is incorrect. A wound can heal and leave a scar.
2. This is incorrect. Although pain is an indicator of inflammation, no pain at the wound site does not indicate proper healing is occurring.
3. This is incorrect. Although drainage is an indicator of inflammation, infection, bleeding, and drainage at the wound site does not indicate proper healing is occurring.
4. This is correct. A healing wound contains granulating tissue.
p. 940
19.
The nurse is assessing the client’s wound and notes that the wound bed shows granulation. What phase of wound healing is described by the nurse’s note?
1. Hemostasis
2. Inflammation
3. Proliferative
4. Maturation
Feedback
1. This is incorrect. Hemostasis is a component of the inflammation phase. At the time of injury, tissue and capillaries are destroyed, causing blood and plasma to leak into the wound. Area vessels constrict to limit blood loss. Platelets aggregate (clump together) to slow bleeding. At the same time, the clotting mechanism is activated to form a blood clot.
2. This is incorrect. The inflammatory reaction is characterized by edema, erythema, pain, temperature elevation, and migration of white blood cells into the wound tissues. Within 24 hours, macrophages begin engulfing bacteria (phagocytosis) and clearing debris. Along with plasma proteins and fibrin, they form a scab on the wound surface, which seals the wound and helps prevent microbial invasion.
3. This is correct. In the proliferation phase, granulation, also called regeneration or healing, occurs from days 5 to 21. Cells develop to fill the wound defect and resurface the skin. Fibroblasts (connective tissue cells) migrate to the wound where they form collagen, a protein substance that adds strength to the healing wound. New blood and lymph vessels sprout from the existing capillaries at the edge of the wound. The result is the formation of granulation tissue, a beefy red tissue that bleeds readily and is easily damaged. As the clot or scab is dissolved, epithelial cells begin to grow into the wound from surrounding healthy tissue and seal over the wound (epithelialization).
4. This is incorrect. In the maturation phase, epithelialization is the final stage of the healing process. Also known as remodeling, this phase begins in the second or third week and continues even after the wound has closed. During the next 3 to 6 months, the initial collagen fibers that were laid in the wound bed during the proliferation phase are broken down and remodeled into an organized structure (e.g., scar tissue), increasing the tensile strength of the wound.
p. 925 (V1)
6.
The nurse is developing a teaching plan for a client that has a surgical incision that has been left open. Which of the following points would the nurse make?
1. The client will need to have twice daily wet to dry dressing changes until the wound is completely healed.
2. The client will need to start a course of antibiotics for the infection until the wound is completely healed.
3. The client will have more scar tissue formation than there would be for a wound closed at surgery.
4. The client should expect to remain hospitalized in an isolation room until the wound is completely healed.
Feedback
1. This is incorrect. There is not enough data to use this teaching point. Wound treatment is individualized, and there is no indication of twice daily wet to dry dressing changes in the narrative.
2. This is incorrect. There is no indication that the wound is infected. Although open wounds are more prone to contamination and infection, this is not an expected outcome, and antibiotics would not necessarily be needed.
3. This is correct. Because the wound edges are not approximated, more scar tissue will form.
4. This is incorrect. A client with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting.
p. 925 (V1)
48.
The home health nurse learns that an elderly client isn’t able to get to the grocery store. She doesn’t have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching television, often not realizing that she has bladder leakage. Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply.
1. Help her to get out of the chair every 2 hours.
2. Change her clothing frequently.
3. Bathe the client using soap and water.
4. Promote intake of green tea throughout the day.
5. Encourage her to wear incontinence products.
Feedback
1. This is correct. Immobility is a major cause of skin breakdown, especially when skin integrity is already compromised with poor nutritional status and poor hydration. Therefore, it is very important for the client to get up out of the chair and move around periodically.
2. This is correct. The moisture from wet clothing is a source of skin breakdown. The nurse would not only need to help the woman put on dry undergarments but also implement a plan for incontinence care, including using protective pads and absorption garments.
3. This is incorrect. Clean skin is important for optimizing skin integrity. However, soap can be drying to the skin, which could increase risk of alterations in skin integrity.
4. This is incorrect. Although this client is at risk for dehydration and undernourishment, which compromises skin integrity, the nurse should educate the client to drink noncaffeinated fluids, especially water. Caffeine can aggravate incontinence.
5. This is correct. The nurse would not only need to help the woman put on dry undergarments but also implement a plan for incontinence care, including using protective pads and absorption garments.
p. 929 (v1)
45.
Why is an accurate description of the location of a wound important? Select all that apply.
1. Influences the rate of healing
2. Determines the appropriate treatment choice
3. Will affect the frequency of dressing changes
4. Affects client movement and mobility
5. Provides cues of wound etiology
Feedback
1. This is correct. Wounds in highly vascular areas heal more rapidly than do wounds in less vascular regions.
2. This is correct. Wounds that can be stabilized also heal more readily than those in areas in which there is movement or pressure. Some wounds can be partially identified by their location. For instance, a venous stasis ulcer occurs in the lower extremities. Therefore, a wound located on an upper extremity would not be related to venous congestion.
3. This is incorrect. The frequency of dressing changes will be dependent on the type of wound and amount of drainage, but not necessarily the location.
4. This is correct. Wounds located on a plantar surface would impede the client’s mobility. Those in a location causing pain would also likely lead to restricted range of motion and movement (mobility).
5. This is correct. Location can give you clues to the wound etiology. A wound over a bony prominence could be related to pressure, whereas one on the bottom of the foot could be a diabetic foot ulcer.
p. 938 (V1)
46.
The nurse learns in report that the assigned client has a stage 3 pressure ulcer. What type of tissue does the nurse expect to visualize in the wound? Select all that apply.
1. Muscle
2. Eschar
3. Subcutaneous tissue
4. Dermis
5. Fascia
Feedback
1. This is incorrect. This would be a stage 4 pressure ulcer.
2. This is incorrect. This would be unstageable pressure ulcer.
3. This is correct. A stage 3 pressure injury is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater.
4. This is correct. A stage 3 pressure injury is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater.
5. This is correct. A stage 3 pressure injury is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater.
p. 918 (v1)
42.
Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply.
1. Granulation
2. Hemostasis
3. Epithelialization
4. Inflammation
5. Maturation
Feedback
1. This is incorrect. In the proliferation phase, granulation, also called regeneration or healing, occurs from days 5 to 21. Cells develop to fill the wound defect and resurface the skin.
2. This is correct. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis.
3. This is incorrect. This is beginning of the proliferation phase, also called the regeneration or healing phase.
4. This is correct. Inflammation follows as a defense against infection at the wound site.
5. This is incorrect. In the maturation phase, epithelialization is the final stage of the healing process, known as remodeling. It begins in the second or third week and continues even after the wound has closed. During the next 3 to 6 months, the initial collagen fibers that were laid in the wound bed during the proliferation phase are broken down and remodeled into an organized structure (e.g., scar tissue), increasing the tensile strength of the wound.
p. 924 (v1)
47.
Which actions would the nurse take when emptying the client’s closed-wound drainage system? Select all that apply.
1. Don sterile gloves and personal protective equipment.
2. Inspect the drainage tube site and suture sites.
3. Check that tubing to drainage system is intact.
4. Test the suction apparatus at the prescribed pressure.
5. Document the color, type, and amount of drainage.
Feedback
1.This is incorrect. Emptying a closed-wound drainage system is not a sterile procedure; therefore, sterile gloves and personal protective equipment (e.g., mask, gown, goggles) would not be necessary. Clean gloves would protect the nurse from contamination and prevent the transmission of microbes with exposure to drainage.
2. This is correct. The nurse would inspect the appearance of the insertion site of the drain for signs of infection or skin irritation.
3. This is correct. The nurse would check the tubing to be sure it is tightly connected and there is no leakage.
4. This is correct. The nurse assesses the suction apparatus to ensure the system is working properly.
5. This is correct. Documentation of the amount and characteristics of the drainage (e.g., color, type, thickness, odor) would aid care providers in assessing the potential for development of wound infection.
p. 942 (V1)