Preview Extract
Chapter 67
1. The nurse admits a client with a large open leg wound from a motor vehicle crash. While
obtaining the history from this client, the nurse inquired about the use of medications. The
client stated he had just completed a course of steroid therapy. The nurse knows the steroids
will:
1. Delay wound healing.
2. Assist in wound healing.
3. Cause an increase in the tendency to bleed.
4. Cause a decrease in the tendency to bleed.
Answer: Delay wound healing.
Rationale:
Steroids suppress the inflammatory phase and thus contribute to a delay in wound healing.
Chronic use of steroids specifically results in decreased production of histamines, which are
needed for the inflammatory response. Steroids do not assist in wound healing, they delay it.
There is no specific impact from steroids on bleeding or clotting.
2. The nurse assessing the wound for the presence of granulation tissue would look for which
normal characteristics of granulation tissue?
Select all that apply.
1. Beefy red
2. Has nodules
3. Moist
4. Has blackened tissue
5. Dry
Answer: 1. Beefy red
2. Has nodules
3. Moist
Rationale:
Beefy red. Granulation tissue appears beefy red and moist. Has nodules. Due to angiogenesis,
granulation tissue develops. Granulation tissue, aptly named for the recognizable tiny, round,
granule-like nodules, is a highly vascular connective tissue that contains newly formed
capillaries, proliferating fibroblasts, and residual inflammatory cells. Moist. Granulation
tissue appears beefy red and moist. Has blackened tissue. Black and/or dry tissue is eschar,
which occurs after a burn injury. Dry. Black and/or dry tissue is eschar, which occurs after a
burn injury.
3. In which stage of wound healing does angiogenesis occur?
1. Proliferation
2. Inflammation
3. Remodeling
4. Maturation
Answer: Proliferation
Rationale:
During proliferation, growth factors originating from injured vessels stimulate the formation
of vascular buds and regrowth of vascular loops. Stimulated endothelial cells multiply and
form tubular structures differentiating into arterioles or venules, a process referred to as
angiogenesis. When injury to the epidermis, dermis, and subcutaneous tissue occurs, the
inflammatory phase of wound healing begins. Within hours after injury, histamines are
released from mast cells, causing local vasodilation and increased capillary permeability. This
allows leakage of serous fluid into the injured site, which results in erythema, edema, and the
production of exudates. The third and final phase of wound healing is maturation or
remodeling, which are synonymous terms. This phase begins after the wound is closed.
During this phase the scar changes and matures. The bulk decreases and the color changes
from pink to pearly white.
4. The nurse is assessing a periwound area on a client with a large abdominal wound, and the
area appears macerated. What change in nursing management is required due to the
maceration?
1. Keep the moist dressing off the periwound area.
2. No new measures are necessary, as this is a normal finding.
3. Apply a moist dressing to the periwound area.
4. Apply a petroleum-based product to the periwound area.
Answer: Keep the moist dressing off the periwound area.
Rationale:
Maceration occurs when excessive moisture destroys the skin’s integrity. Periwound skin
becomes macerated when the wet dressing from the wound extends to the skin around the
wound. The most appropriate nursing measure is to not have any wet dressing touching the
skin around the wound. Maceration is not a normal finding and requires nursing intervention.
Applying moist dressings to the periwound area would worsen the maceration. Applying a
petroleum dressing to the periwound is not necessary. All that is necessary is to keep the area
dry and let the skin heal.
5. The nurse is caring for a client with a large open wound. While doing the dressing change,
the nurse notes purulent drainage. What additional assessments are necessary for this client?
Select all that apply.
1. White blood count
2. Fever
3. Wound odor
4. Wound bleeding
5. Blood urea nitrogen (BUN)
Answer: 1. White blood count
2. Fever
3. Wound odor
Rationale:
White blood count. Purulent drainage indicates infection, which requires the nurse to assess
for other indicators of infection. Increased white blood count is another positive indicator of
infection. Fever. Fever is an indicator of the presence of infection. Wound odor. Some types
of organisms have a distinct odor, such as pseudomonas. The wound should be assessed for
the presence of odor. Wound bleeding. Bleeding is not an indicator of infection. Blood urea
nitrogen (BUN). BUN is an indicator of renal function, not wound infection.
6. The nurse is caring for an 84-year-old client who was just admitted from a nursing home
with a large sacral ulcer. When assessing the wound, the nurse notes small areas of both black
and white tissue in the wound bed. The nurse understands that the best dressing protocol for
this wound is:
1. Wet-to-dry with normal saline every 6 hours.
2. Petroleum-based antiseptic dressing once per day.
3. Dry dressing twice per day.
4. Wet-to-wet with Dankins solution once per day.
Answer: Wet-to-dry with normal saline every 6 hours.
Rationale:
The black and white tissue needs to be debrided from the wound area before healing can
occur. Wet-to-dry dressing provides a means of debridement. Petroleum-based products will
not provide debridement. Dry dressing and wet-to-wet Dankins solution also will not provide
the needed debridement.
7. The nurse understands that certain clients are more susceptible to pressure ulcer
development. Which of the following clients would be at an increased risk?
Select all that apply.
1. Clients who have restricted activity
2. Clients with decreased sensation
3. Clients with poor nutrition
4. Clients who are very thin
5. Clients who have urinary or fecal incontinence
Answer: 1. Clients who have restricted activity
2. Clients with decreased sensation
3. Clients with poor nutrition
4. Clients who are very thin
5. Clients who have urinary or fecal incontinence
Rationale:
Clients who have restricted activity. Clients who have restricted activity, as would occur with
quadriplegia, strokes, and fractured hips, are at risk for pressure ulcer development. Clients
with decreased sensation. Decreased sensation prevents clients from feeling the pain
associated with the development of a pressure ulcer, which increases the risk of development
and progression. Clients with poor nutrition. Clients with poor nutrition are more susceptible
to pressure ulcer development. Clients who are very thin. Clients who are very thin or have
decreased protein in the diet have skin that is more likely to ulcerate. Clients who have
urinary or fecal incontinence. Clients who have urinary or fecal incontinence or are exposed
to other types of moisture such as perspiration, wound drainage, or emesis are more prone to
ulcers.
8. When assessing a client for the risk of pressure ulcer development, what factors must be a
part of the assessment?
Select all that apply.
1. Sensory perception and activity level
2. Moisture
3. Mobility
4. Nutrition
5. Friction and shear
Answer: 1. Sensory perception and activity level
2. Moisture
3. Mobility
4. Nutrition
5. Friction and shear
Rationale:
Sensory perception and activity level. Decreased sensation increases the risk for pressure
ulcer development. Decreased activity increases the risk for pressure ulcer development due
to prolonged pressure in one area, thereby decreasing the circulation to that area, resulting in
decreased oxygen supply. Moisture. Moisture increases skin breakdown, thereby increasing
the risk for pressure ulcer development. Mobility. Decreased mobility level increases the risk
for pressure ulcer development due to prolonged pressure in one area. Nutrition. Nutrition
supplementation is an essential intervention for pressure ulcer development. Protein is the
building block for collagen synthesis, interstitial fluid balance, granulation, and
epithelialization. Friction and shear. Friction and shear potentially remove layers of tissue,
thereby increasing the risk for loss of skin integrity, which can progress to necrosis of the
skin with pressure.
9. The nurse understands that in order to prevent pressure ulcer development, he must remove
pressure from high-risk areas of the body. What nursing interventions are essential to
accomplish this goal?
Select all that apply.
1. Use pillows to offload pressure.
2. Turn the client at least every 2 hours.
3. Use a shoe or cast to prevent pressure.
4. Keep the client on bed rest.
5. Pull the client up in bed every 2 hours or less.
Answer: 1. Use pillows to offload pressure.
2. Turn the client at least every 2 hours.
3. Use a shoe or cast to prevent pressure.
Rationale:
Use pillows to offload pressure. Pillows provide a cushion for bony prominences, which
decreases pressure. Turn the client at least every 2 hours. Turning takes prolonged pressure
off a single area. Use a shoe or cast to prevent pressure. Shoes and properly padded casts
protect high-risk areas from pressure by providing a barrier and a cushion. Keep the client on
bed rest. This would be inappropriate, as activity and mobility prevent prolonged pressure in
one area. Pull the client up in bed every 2 hours or less. Pulling clients up in bed increases
friction and shear, but does not prevent pressure.
11. The nurse is caring for a frail elderly client who has a chronic pressure ulcer. The nurse
understands that this wound is not healing due to:
Select all that apply.
1. An inadequate blood supply in the tissue.
2. Repeated prolonged insults to the tissue.
3. Disruptive underlying pathologic processes.
4. Recent trauma.
5. Pneumonia.
Answer: 1. An inadequate blood supply in the tissue.
2. Repeated prolonged insults to the tissue.
3. Disruptive underlying pathologic processes.
Rationale:
An inadequate blood supply in the tissue. Chronic wounds generally occur due to inadequate
blood supply in the tissue. Repeated prolonged insults to the tissue. Chronic wounds
generally occur due to repeated prolonged insults to the tissue. Disruptive underlying
pathologic processes. Chronic wounds generally occur due to disruptive underlying
pathologic processes. Recent trauma. Recent trauma is associated with acute traumatic
wounds. Pneumonia. Pneumonia is not directly related to wound healing.
13. Factors that promote development of a wound in a client with a ___________ are
neuropathy, macrovascualar and microvascular changes, and a diminished immunity.
1. Diabetic wound
2. Pressure ulcer
3. Venous stasis ulcer
4. Traumatic wound
Answer: Diabetic wound
Rationale:
The mitigating factors that promote development of a wound in a client with diabetes are
neuropathy, macro- and microvascular changes, and a slow, decreased immune response.
Pressure ulcers develop when pressure causes decreased circulation to an area. Venous ulcers
are caused by vein harvesting for coronary artery bypass grafting, pregnancy, and occupations
necessitating prolonged standing or sitting, which leads to venous congestion and the
development of venous ulcers. Traumatic wounds are those caused by fire, guns, knives,
vehicular crashes, and so on, and are not related to neuropathy, micro- and macrovascular
changes, and diminished immunity.
14. Follow-up teaching for a client who has just had a squamous cell carcinoma removed
from the skin must include:
Select all that apply.
1. Inspecting the skin vigilantly on a routine basis.
2. Having caregiver inspect the hard-to-visualize areas of the body.
3. Reporting any suspicious-looking areas to the primary health care provider.
4. Using sunscreen routinely.
5. Covering areas where the cancer has occurred with clothing or hats.
Answer: 1. Inspecting the skin vigilantly on a routine basis.
2. Having caregiver inspect the hard-to-visualize areas of the body.
3. Reporting any suspicious-looking areas to the primary health care provider.
4. Using sunscreen routinely.
5. Covering areas where the cancer has occurred with clothing or hats.
Rationale:
Inspecting the skin vigilantly on a routine basis. It is important to inspect the skin regularly
for a recurrence of cancer. Having caregiver inspect the hard-to-visualize areas of the body. It
is important to have the health care provider inspect the client’s skin regularly for a
recurrence of cancer. Reporting any suspicious-looking areas to the primary health care
provider. Reporting of a suspicious lesion is essential so as to not have the cancer spread.
Using sunscreen routinely. Using sunscreen will protect the skin from the sun’s harmful
ultraviolet rays. Covering areas where the cancer has occurred with clothing or hats.
Covering the skin is another way of protecting it from the sun’s harmful ultraviolet rays.
15. The nurse is caring for a client with a large wound on her right hip. What nursing measure
is the most essential for the client?
1. Keep the client from lying on her right side.
2. Turn the client from side to side every 2 hours.
3. Keep the client on continuous bed rest.
4. Keep the client upright in a chair for a minimum of 8 hours per 24-hour period.
Answer: Keep the client from lying on her right side.
Rationale:
Keeping pressure off the right hip is the essential nursing measure because pressure will
decrease blood flow to the area. Blood flow is needed to get oxygen and nutrients to the area
in order to heal the wound. Turning the client from side to side is inappropriate because she
would be lying on her wound, creating pressure that would diminish the blood supply. A right
hip wound does not require complete bed rest or prolonged chair sitting.
16. The nurse is caring for a client with a deep wound that has tunneling. Following the
dressing change, what factors are essential for the nurse to document?
Select all that apply.
1. Size and shape of the tunnel
2. Direction and number of tunnels
3. Type of drainage coming from the wound
4. Length of dressing needed to pack wound
5. Amount of irrigation poured into the tunnel
Answer: 1. Size and shape of the tunnel
2. Direction and number of tunnels
3. Type of drainage coming from the wound
4. Length of dressing needed to pack wound
Rationale:
Size and shape of the tunnel. The size and shape of the tunnel must be documented so the
next person changing the dressing has that information as a guide. Direction and number of
tunnels. The amount of tunnels and their direction must be documented so that the next
person changing the dressing has that information as a guide. Type of drainage coming from
the wound. It is essential to document the type of drainage in order to evaluate for the
presence of infection. Length of dressing needed to pack wound. It is essential to document
the length of dressing to provide information about the depth of the tunnel. Amount of
irrigation poured into the tunnel. Irrigation is not indicated during the dressing change for
tunneled wounds.
17. Specialty support surfaces are mattresses or overlays that provide pressure reduction or
pressure relief. When making a decision about which mattress/overlay would be appropriate
for a client, the nurse must consider which of the following factors?
Select all that apply.
1. Risk for skin breakdown
2. Presence of ulcers or wounds
3. Mobility status
4. Moisture and continence issues
5. Nutrition status
Answer: 1. Risk for skin breakdown
2. Presence of ulcers or wounds
3. Mobility status
4. Moisture and continence issues
5. Nutrition status
Rationale:
Risk for skin breakdown. High-risk clients for pressure ulcers, such as the frail and elderly,
should be placed on a special support surface prophylactically. Presence of ulcers or wounds.
If a client currently has pressure ulcers he or she should be placed on a special mattress to
prevent progression of the current ulcers and formation of new ones. Mobility status. The
client’s level of mobility is a factor due to the increased risk of pressure ulcer development in
clients who are unable or unwilling to move. Moisture and continence issues. Incontinent
clients or clients who perspire excessively are at an increased risk for skin breakdown due to
maceration. They need to be placed on a special mattress to prevent further breakdown from
pressure. Nutrition status. Inadequate nutrition will increase the risk of skin breakdown. If a
client is malnourished, it is an indication that he or she would benefit from a special mattress
to help decrease skin breakdown.
18. Tracing graphs of transparent film are used to assess wound healing rates. The advantages
of these assessment tools are that they:
Select all that apply.
1. Enable health care providers to outline the shape of the wound.
2. Show progress of the wound surface contracture.
3. Offer a psychological boost to clients whose wounds are healing by millimeters.
4. Prevent infection from iatrogenic causes.
5. Keep the wound dry.
Answer: 1. Enable health care providers to outline the shape of the wound.
2. Show progress of the wound surface contracture.
3. Offer a psychological boost to clients whose wounds are healing by millimeters.
Rationale:
Enable health care providers to outline the shape of the wound. Tracing graphs of transparent
film, such as E-Z Graph System of wound assessment, enable health care providers to outline
the shape of the wound. Show progress of the wound surface contracture. Tracing graphs of
transparent film, such as E-Z Graph System of wound assessment, enable health care
providers to show progress of the wound surface contracture. Offer a psychological boost to
clients whose wounds are healing by millimeters. These tracings offer a great psychological
boost to clients whose wounds are healing by millimeters, when they can see progress as
compared to original wound size. Prevent infection from iatrogenic causes. Tracings are not
used to prevent infection, they are used to assess wound healing. Keep the wound dry.
Tracings are not used to keep wounds dry: they are used to assess wound healing.
19. The nurse is employed in a long-term care facility. The nurse understands that the Joint
Commission mandates the documentation of:
Select all that apply.
1. Pressure ulcer incidence.
2. Measures taken to prevent pressure ulcers.
3. Periodic care plan revisions.
4. Staffing ratios.
5. Client census.
Answer: 1. Pressure ulcer incidence.
2. Measures taken to prevent pressure ulcers.
3. Periodic care plan revisions.
Rationale:
Pressure ulcer incidence. The Joint Commission mandates that hospitals must have quality
assurance records regarding pressure ulcer incidence. Measures taken to prevent pressure
ulcers. The Joint Commission mandates that hospitals must have quality assurance records
regarding pressure ulcer prevention. Periodic care plan revisions. The Joint Commission
mandates that hospitals must keep quality assurance records current. Staffing ratios. Staffing
ratio regulations are not related to pressure ulcer incidence and prevention. Client census.
Client census regulations are not related to pressure ulcer incidence and prevention.
20. The nurse is caring for a young client with a large wound on the arm from necrotizing
fasciitis. The nurse knows this client has psychologically adjusted to this wound when the
client states:
1. “I am able to look at my wound during dressing changes.”
2. “I told my family it would heal without a scar.”
3. “I will wear long sleeves for the rest of my life.”
4. “I told my mother that she should not look at the wound.”
Answer: “I am able to look at my wound during dressing changes.”
Rationale:
Looking at the wound during dressing changes is a sign that the client is beginning to accept
the fact that the wound is there. Telling the family it will heal without a scar is denial on the
part of the client. Full-thickness injures always leave scars. Wearing long sleeves means that
the client does not want anyone to see the scar, which is an indication that the client is
bothered by the wound. Telling her mother that she should not look at the wound is not an
indication that the client has accepted the wound.
21. To best promote wound healing and prevent infection, research supports the use of:
1. Topical silver.
2. Topical gold.
3. Normal saline.
4. Dankins solution.
Answer: Topical silver.
Rationale:
Silver is a product that has come into wide use as a local antimicrobial agent, and continues
to be a topic of research. Gold is not a wound care product. Normal saline and Dankins
solutions are not antimicrobial agents, and therefore are not used for infection prevention.
22. Wound breakdown after healing continues to be an issue with burn victims. Research into
__________would help diminish this problem.
1. Techniques to increase tensile strength
2. Techniques to decrease wound infection
3. Methods to increase client compliance
4. Methods to increase family participation
Answer: Techniques to increase tensile strength.
Rationale:
Wound breakdown is related to the tensile strength of the scar. Techniques to increase tensile
strength would decrease wound breakdown. Techniques to decrease wound infection would
not increase tensile strength of healed wounds. Client compliance and family participation
have no direct effect on wound strength.
23. In order to have wound healing occur, the client must receive adequate nutrition. Diets
must be high in protein and calories with vitamin and nutritional supplements. Evidence
supports that what additional requirements are needed for wound closure?
Select all that apply.
1. Supplemental amino acids
2. Supplemental fat-soluble vitamins
3. Supplemental water-soluble vitamins
4. Supplemental antioxidants
5. Supplemental fluids
Answer: 1. Supplemental amino acids
2. Supplemental fat-soluble vitamins
3. Supplemental water-soluble vitamins
4. Supplemental antioxidants
5. Supplemental fluids
Rationale:
Supplemental amino acids. Supplemental amino acids include arginine, glutamine, and
hydroxy-methyl butyrate (HMB), which promote tissue growth and wound healing.
Supplemental fat-soluble vitamins. Fat soluble vitamins such as A, D, E, and K play a role in
the wound healing process. Supplemental water-soluble vitamins. Water-soluble vitamins
such as C and the B family are needed for wound healing. Supplemental antioxidants.
Antioxidants enhance cell membrane stability and promote wound healing. Supplemental
fluids. Maintaining adequate hydration assists in healing and decreases the risk of
development of additional wounds.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
