Skin Integrity and Wound Care

Skin Integrity and Wound Care
7. Which skin care measures are used to manage a patient who
is experiencing fecal and urinary incontinence?
1. Keeping the buttocks exposed to air at all times
2. Using a large absorbent diaper, changing when saturated
3. Using an incontinence cleaner, followed by application of a
moisture-barrier ointment
4. Frequent cleaning, applying an ointment, and covering the
areas with a thick absorbent towel
8. Which of the following describes a hydrocolloid dressing?
1. A seaweed derivative that is highly absorptive
2. Premoistened gauze placed over a granulating wound
3. A debriding enzyme that is used to remove necrotic tissue
4. A dressing that forms a gel that interacts with the wound
surface
9. Which of the following is an indication for a binder to be
placed around a surgical patient with a new abdominal
wound?
1. Collection of wound drainage
2. Reduction of abdominal swelling
3. Reduction of stress on the abdominal incision
4. Stimulation of peristalsis (return of bowel function) from
direct pressure
10. When is an application of a warm compress indicated? (Select
all that apply.)
1. To relieve edema
2. For a patient who is shivering
3. To improve blood flow to an injured part
4. To protect bony prominences from pressure ulcers
11. What is the removal of devitalized tissue from a wound called?
1. Debridement
2. Pressure reduction
3. Negative pressure wound therapy
4. Sanitization
12. Name the three important dimensions to consistently measure
to determine wound healing.
13. What does the Braden Scale evaluate?
1. Skin integrity at bony prominences, including any wounds
2. Risk factors that place the patient at risk for skin
breakdown
3. The amount of repositioning that the patient can tolerate
4. The factors that place the patient at risk for poor healing
14. On assessing your patient’s sacral pressure ulcer, you note that
the tissue over the sacrum is dark, hard, and adherent to the
wound edge. What is the correct stage for this patient’s pressure ulcer?
1. Stage II
2. Stage IV
3. Unstageable
4. Suspected deep tissue damage
15. Name one intervention and the rationalization to use that
intervention to reduce the likelihood of a shear injury to a
patient.

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