Chapter 36 Skin Integrity My Nursing Test Banks PDF

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Chapter 36 My Nu Nursing rsing T Test est Banks Kozier & Erbs Fundamentals of Nursing,, 10/E Chapter 36 Question 1 Type: MCSA The continuous quality improvement team is monitoring the nursing care of cleancontaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection Correct Answer: 3 Rationale 1 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. A gastric resection would be included in the study. Rationale 2 2: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. An uncomplicated abdominal hysterectomy would be included in the study. Rationale 3 3: A breast biopsy is considered a clean wound. Clean wounds are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds. Rationale 4 4: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. A lung resection would be included in the study. Global R Rationale: ationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy; Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify the main complications of and factors that affect wound healing. MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity. Page Number: 829 Question 2 Type: MCSA The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the clients bowel resection. For which category of wound should the receiving nurse plan care for this client? 1. Clean-contaminated 2. Contaminated 3. Dirty 4. Infected Correct Answer: 2 Rationale 1 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered, but minimal to no spillage has occurred. Rationale 2 2: A surgical wound in which there is a large amount of spillage from the gastrointestinal tract is considered a contaminated wound. Rationale 3 3: A dirty wound is one that contains dead tissue or that has evidence of a clinical infection, such as purulent drainage. Rationale 4 4: An infected wound is one that contains dead tissue or that has evidence of a clinical infection, such as purulent drainage. Global R Rationale: ationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Identify the main complications of and factors that affect wound healing. MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity. Page Number: 829 Question 3 Type: MCSA A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for this clients care? 1. Obtain ice packs to apply to the wounds. 2. Request gauze to pack the wounds. 3. Organize suture material to close the wounds. 4. Notify the surgical staff that a surgical client will soon be arriving. Correct Answer: 1 Rationale 1 1: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Rationale 2 2: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Because these wounds are closed, there is no need for packing. Rationale 3 3: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Because these wounds are closed, there is no need for suturing. Rationale 4 4: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Because these wounds are closed, there is no need for surgery.

Global R Rationale: ationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 829 Question 4 Type: MCSA After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? 1. Reactive hyperemia 2. Stage I pressure ulcer 3. Stage II pressure ulcer 4. Stage III pressure ulcer Correct Answer: 1 Rationale 1 1: If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred. Rationale 2 2: Stage I pressure ulcers are reddened areas that do not blanch with thumb pressure and that do not clear in the allotted amount of time.

Rationale 3 3: Stage II pressure ulcers show partial-thickness skin loss and have the appearance of abrasions, blisters, or shallow craters. Rationale 4 4: Stage III pressure ulcers demonstrate full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Global R Rationale: ationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe the four stages of pressure ulcer development. MNL Learning Outcome: 4.6.2. Compare the stages of pressure ulcer development and types of wound healing. Page Number: 830 Question 5 Type: MCSA The nurse assesses an open area over a clients greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer? 1. There is undermining of adjacent tissues. 2. The crater extends into the subcutaneous tissue. 3. The joint capsule of the hip is visible. 4. The ulcer has thick dark eschar over the top. Correct Answer: 3

Rationale 1 1: Undermining of adjacent tissues can occur in either a stage III or stage IV pressure ulcer. Rationale 2 2: Extension into the subcutaneous tissue is a characteristic of a stage III pressure ulcer. Rationale 3 3: Stage IV ulcers demonstrate damage to muscle, bone, tendons, or the joint capsule. Rationale 4 4: If there is eschar present, the ulcer cannot be staged. Staging can occur only when the bottom of the ulcer can be seen and evaluated. Global R Rationale: ationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the four stages of pressure ulcer development. MNL Learning Outcome: 4.6.2. Compare the stages of pressure ulcer development and types of wound healing. Page Number: 831 Question 6 Type: MCSA The UAP reports a small skin tear on the clients forearm that occurred during a routine turn. After assessing the wound the nurse should take which action? 1. Obtain a transparent dressing for the UAP to place on the wound. 2. Request a consult with the wound care nurse. 3. Cleanse the wound and apply a dressing. 4. Tell the UAP to reevaluate the wound in 20 minutes.

Correct Answer: 3 Rationale 1 1: The UAP is not educationally prepared to dress the wound. Rationale 2 2: At this point a consult with the wound care nurse is not required. Rationale 3 3: The nurse should go to the room, assess the wound, cleanse the wound, and apply a dressing. Rationale 4 4: The UAP is not educationally prepared to evaluate the wound. Global R Rationale: ationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 847 Question 7 Type: MCSA The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse 1. should receive specific training. 2. must be certified. 3. is required to ask the clients permission. 4. has to obtain special assessment equipment. Correct Answer: 1

Rationale 1 1: The nurse should receive specific training in the use of the Braden scale in order for assessment to be accurate. Rationale 2 2: The nurse does not need to be certified in the use of the Braden Scale. Rationale 3 3: There is no specific permission required from the client. Rationale 4 4: There is no special assessment equipment required. Global R Rationale: ationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 833 Question 8 Type: MCSA A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores? 1. Trending can only be accurate if the same scale is used. 2. There is a definite trend of low risk for pressure ulcer development. 3. Trending would be more accurate if the same scale was used. 4. The scores indicate opposite risks for pressure ulcer development. Correct Answer: 3

Rationale 1 1: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. Rationale 2 2: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. Rationale 3 3: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. Rationale 4 4: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. Global R Rationale: ationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 832 Question 9 Type: MCSA A clients laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing? 1. Primary intention 2. Open approximation 3. Secondary healing

4. Delayed closure Correct Answer: 1 Rationale 1 1: The nurse should instruct the client regarding primary intention wound healing. The edges of these wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds. Rationale 2 2: Secondary healing involves wounds that cannot be approximated and that must heal in. Rationale 3 3: Secondary healing involves wounds that cannot be approximated and that must heal in. These wounds are at higher risk for infection, take longer to heal, and are more prone to scarring. Rationale 4 4: Wounds that are left open for 3 to 5 days allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by tertiary intention. This is also called delayed primary intention. Global R Rationale: ationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Differentiate primary and secondary wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 834 Question 10 Type: MCSA A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause

1. decreased oxygen supply to tissues. 2. suppression of the inflammatory process necessary for healing. 3. a decrease in the amount of nutrients such as glucose in the blood. 4. blood vessel constriction, which impairs waste product removal. Correct Answer: 2 Rationale 1 1: Steroids do not decrease oxygen supply to the tissues. Rationale 2 2: Steroids suppress the inflammatory process, which is a normal part of the healing process. Rationale 3 3: Steroids generally increase blood glucose. Rationale 4 4: Blood vessels are not constricted by steroids. Global R Rationale: ationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 835 Question 11 Type: MCSA On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that something popped in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first? 1. Notify the clients surgeon.

2. Cover the area with a large saline-soaked dressing. 3. Position the client in bed with knees bent. 4. Pack the wound with nonadherent gauze. Correct Answer: 2 Rationale 1 1: Although notifying the surgeon is important, it is not the nurses first action. Rationale 2 2: Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The nurses first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist. Rationale 3 3: Although positioning the client is important, it is not the nurses first action. Rationale 4 4: Nothing should be packed into this wound. Global R Rationale: ationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. ...