Chapter 52- Patient Management- Integumentary System. My Nursing Test Banks

 

1.

A nurse is caring for a patient in the ICU. During assessment of the skin she notices a wound on the patients coccyx that is covered in a brown leathery tissue-like material. Which of the following is the patient exhibiting?

A)

Stage III pressure ulcer

B)

Unstageable pressure ulcer

C)

Abrasion

D)

Stage II pressure ulcer

E)

Suspected deep tissue damage

2.

Which of the following is the final phase of wound healing?

A)

Proliferative phase

B)

Maturation phase

C)

Inflammatory phase

D)

Epitheliazation phase

E)

Granulization phase

3.

A nurse performs a visual assessment of a wound during the inflammatory phase of healing. Which of the following observations does the nurse make? Select all that apply.

A)

Bleeding

B)

Erythema

C)

Edema

D)

Scarring

E)

Itching

F)

Pain

4.

Which of the following are precipitating factors that can cause a chronic wound to fail to follow a sequential healing process? Select all that apply.

A)

Rest

B)

Diabetes

C)

Infection

D)

Mobility

E)

Malnutrition

F)

Peripheral vascular disease

5.

A nurse is caring for a patient with a skin tear. Which of the following is included in this care? Select all that apply.

A)

Clean the wound with normal saline.

B)

Clean the wound with hydrogel.

C)

Cover the wound with a self-adherent dressing.

D)

Tape the dressing in place to avoid displacement.

E)

Apply hydrogel before cleansing the wound.

F)

Wrap the wound with a nonadherent dressing.

6.

The nurse is providing education to a patient related to wound healing. Which specific nutritional components that are needed by the body to heal will the nurse include in the teaching? Select all that apply.

A)

Sugar

B)

Carbohydrates

C)

Protein

D)

Water

E)

Fats

F)

Minerals

7.

Which of the following is indicative of tertiary intention?

A)

During this time the wound is packed or irrigated to remove exudate and cellular debris.

B)

The edges of the wound are drawn together shortening the time required for the wound to heal.

C)

The wound is closed immediately to prevent infection.

D)

It is associated with a decreased risk for infection and minimal scarring.

E)

The wound is cleansed and then covered with a non-adhesive dressing.

F)

The wound is left open to air and cleansed daily with normal saline.

8.

The nurse is preparing to cleanse a pressure wound on a patient. Which of the following solutions are the nurses best choices for cleansing the wound? Select all that apply.

A)

Hydrogen peroxide

B)

Normal saline

C)

Acetic acid

D)

Provodone-iodine

E)

Commercial wound cleansers

F)

Dakins solution

9.

A nurse is caring for a patient with multiple chronic wounds over her body. Which of the following is characteristic of a chronic wound?

A)

Caused by surgery or trauma

B)

Follows a disorderly healing process

C)

Follows an orderly healing process

D)

Only occurs with patients who have diabetes

10.

A nurse is caring for patients exhibiting stage III and IV pressure ulcers. Which of the following dressings is the nurse most likely to use on these patients? Select all that apply.

A)

Nonadhesive dressing

B)

Calcium alginate dressing

C)

Dry dressing

D)

Wet saline dressing

E)

Hydrofiber dressing

F)

Rope dressing

11.

The patient has a wound from peripheral vascular disease that is not healing in an orderly, sequential manner, and the patient has diminished functional integrity. How does the nurse label this wound?

A)

Acute

B)

Chronic

C)

Nonhealing

D)

Partial thickness

12.

The patient has a peripheral vascular ulcer that involves loss of the epidermis, dermis, and subcutaneous tissue. Muscle and tendons are visible at the deepest part of the wound. How does the nurse classify this wound?

A)

Stage II

B)

Stage III

C)

Superficial

D)

Full thickness

13.

The patient has a pressure ulcer that was classified as a stage III ulcer. With care, the ulcer has partially healed and now appears as an area of nonblanchable erythema with mild edema. What is the most appropriate nursing description?

A)

Stage I ulcer

B)

Stage III ulcer, healing

C)

Stage III to I ulcer

D)

Stage III ulcer, exacerbated

14.

The nurse is caring for a patient with a traumatic wound that is 4 days old. The wound is erythematous, edematous, and painful. The nurse assesses the wound as being in what phase of healing?

A)

Proliferation

B)

Epithelialization

C)

Inflammatory

D)

Maturation

15.

An elderly patient has a wound that is slow to heal. What normal aging characteristic is most likely to be a factor in slow wound healing?

A)

Inefficient immune system

B)

Slower reflexes and reaction time

C)

Diminished pulmonary compliance

D)

Lengthened recall time for events

16.

The patient has a surgical wound with the edges approximated by sutures. By what method does the nurse expect this wound to heal?

A)

Naturally

B)

Primary intention

C)

Secondary intention

D)

Tertiary intention

17.

The patient has a pressure ulcer that is being allowed to heal by secondary intention. What is the most significant complication of this type of wound healing?

A)

Venous stasis

B)

Arterial insufficiency

C)

Scar formation

D)

Wound infection

18.

The nurse is caring for a patient with a traumatic wound. What is the best way to describe the size of the wound?

A)

Actual measurements in three dimensions

B)

Compare to size of a common object

C)

State percentage of body affected

D)

Diameter at widest part in centimeters

19.

The nurse is preparing to clean a deep wound. What cleaning solution is the safest for all wounds?

A)

Normal saline

B)

Povidone-iodine

C)

Dakins solution

D)

Hydrogen peroxide

20.

The patients wound is being treated with vacuum-assisted wound closure (negative pressure therapy, or VAC). The nurse notices that the edge of the dressing is loose and torn, the foam in the wound has expanded, and wound drainage is leaking through the loose edge. What is the best nursing action?

A)

Reinforce dressing with additional foam packing.

B)

Reinforce transparent adhesive dressing.

C)

Discontinue suction on the wound to prevent maceration.

D)

Completely redress the wound with new materials.

21.

The patient has a large, deep wound from trauma that is being treated with constantly moist saline and gauze packing. Before cleaning and redressing the wound, what is the most important nursing intervention?

A)

Gather necessary supplies.

B)

Read previous documentation.

C)

Premedicate for pain.

D)

Explain procedure to patient.

22.

A critically ill patient with a large, deep, open traumatic wound has diminished serum albumin and total protein, diminished lymphocytes, and low iron levels. The patient has a history of alcohol abuse and is currently being supported with enteral nutrition, but the feeding is being held for excess residual volumes. What impact would the patients situation have on wound healing?

A)

Diminished healing with increased risk of infection

B)

Improved healing secondary to the enteral nutrition

C)

Healing by primary intention has the lowest risk.

D)

Normal healing unless wound is infected

Answer Key

1.

B

2.

B

3.

B, C, F

4.

B, C, E, F

5.

A, E, F

6.

B, C, D, F

7.

A

8.

B, E

9.

B

10.

B, E

11.

B

12.

D

13.

B

14.

C

15.

A

16.

B

17.

D

18.

A

19.

A

20.

D

21.

C

22.

A

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