Care of the Skin

1. During a dressing change, inspection of the wound reveals what appears to be reddish pink tissue in the wound. The nurse interprets this as most likely: A. A sign of infection B. Eschar C. Exudate D. Granulation Tissue Answer: The correct answer is D. Granulation tissue is new tissue composed of many small blood vessels, is pinkish red, and fills an open wound when it starts to heal. 2. Which intervention should the nurse expect to use for applying moist heat? A. Sitz bath B. Aquatermia pad C. Heat lamp D. Commercial Hot pack Answer: The correct answer is A. A sitz bath is a moist heat application. All the other options are dry heat. 3. When assessing a patient at risk for pressure ulcer formation, which site should the nurse identify as being most common? A. Occipital Area B. Sacrum C. Sternum D. Humerus Answer: The correct answer is B. All sites involve bony prominences, but the sacrum is the most common area where pressure ulcer develops. 4. When explaining about factors contributing to pressure ulcer, which factor should the nurse describe as key? A. Moisture B. Incontinence C. Pressure D. Malnutrition Answer: The correct answer is C. Pressure is a key factor contributing to a pressure ulcer. It interferes with circulation to the cell, resulting in cell death.

5. Which term would the nurse use to document wound drainage that is thick, odorous and green?

A. Serous B. Sanguineous C. Serosangeneous D. Purulent Answer: The correct answer is D. Purulent drainage is the result of an infection and is thick odorous and colored. 6. After an initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer is classified as: A. Stage I B. Stage II C. Stage III D. Stage IV Answer: The correct answer is B. a stage II pressure ulcer is superficial and presents clinically as an abrasion, ulcer or shallow crater. 7. An older confused patient sits and slumps in her chair most of the day. She is most likely to develop a pressure ulcer because of: A. Malnutrition B. Shearing Forces C. Edema D. A chronic Disease Answer: The correct answer is B. Sitting slumped in chair for an extended period can easily result in shearing force, causing a pressure ulcer. 8. After a surgical incision, a patient often has an elevated body temperature and generalized malaise. These manifestations most often occur during which phase of wound healing? A. Inflammatory B. Primary C. Fibroplasia D. Maturation Answer: The correct answer is A. Systemic manifestations occur as a result of the inflammatory response to the altered skin and tissue integrity. It does not usually continue into the fibroplasia and maturation phases of wound healing. 9. A. B. C. D. The nurse assesses a stage III pressure ulcer manifested as: Redness that persists when pressure ulcer is relieved. An open lesion with subcutaneous tissue exposed A necrotic area extending through the fascia to bone A reddened area with an abrasion

Answer: The correct answer is B. A stage III pressure ulcer is an open lesion that exposes subcutaneous tissue. 10. Which action would be a priority in preventing a patient from developing a pressure ulcer? A. Using a water proof material on the bed B. Massaging any reddened area frequently C. Using an air-inflated ring to relieve pressure on areas D. Using a mild soap when cleaning the skin Answer: The correct answer is D. Using a mild soap is less irritating. The skin should be rinsed and dried thoroughly.