Unit no:36 Skin Integrity and Wound Care

MCQs:

1. Your client has a Braden scale score of 17. Which is the appropriate nursing
action?
1- Assess the client again in 24 hours; the client is at increasesd risk of skin breakdown.
2- Impliment a turning schedule; the client is at increased risk of skin breakdown.
3- Apply a transeparent wound barrier to major pressuresites; the client is at increased
risk of skin breakdown.
4- Request an order for a special low-air-loss bed; the client is at a very high risk of
infection.

2. Proper technique for performing a wound culture includes which of the following?

1- Cleansing the wound prior to obtain the speciemen.

2- Swabbing for the speciemen in the area with the largest collection of drainage.
3- Removing crusts or swabs with sterile forceps and then culturing the site beneath.
4- Waiting 8 hours following a dose of antibiotic to obtain the speciemen.

3. A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but
no necrotic areas. The nurse would treat the area with which dressing?

1- Aliginate
2- Dry gauze
3- Hydrocolloid
4- No dressing is indicated

4. Thirty mints after application is initiated, the client requests that the nurse leave the
heating pad in place.The nurse explain the following to client:

1- Heat application for longer then thirty minutes can actually cause the opposite
effect of the desired one.
2- It will be acceptable to leave the pad in place if the temperature is reduced.
3- It will acceptable to leave the pad iin place for another 30 minutes if the site appears
satisifactorywhen assessed.
4- It wil be acceptable to leave the pad in place as long as it is moist heat.

5. Which ststement, if made by the cliemt or family member, would indicate the need
for further teaching?

1- “If a skin area gets red but then the red goes away after turning, I should report it to
the nurse”.
2- “Putting fosm pads umder my heals and oter bony areas can help decreas pressure”.
 3- “If my father can not turn himself in bed . I should help in change position every
4 hours.
4- The skin should be washed with only warm water and lotion put on while it is still a
little wet.

6. Your client is only comfortable lying on the right or left side. List four potential sites
for pressure ulcers you must assess.

1- Shouder
2- Ear
3- Ankle
4- Knees

7. An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting
from scratching an allergic rash is:

1- Risk for impaired skin integrity

2- Impaired skin integrity

3- Impaired skin integrity

4-Risk for infection

8.Which of the following are primary risk factors for pressure alcers? Select all that
apply.

1- Low protein diet

2- Insomnia

3- Lengthy surgical procedures

4-Fever

9.Which of the following items are used to perform wound irrigation?Select all that
apply.

1- clean glove

2- Sterile gloves

3- Refrigerated irrigating solution

4-60 ml syringe

5- Forceps

10.Which of the following indicates proper use a triangle arm single?

1- The elbow is kept flexed at 90° or more.

 2- The knote is placed on either side of the vertebrae of the neck.

3- The sling extends to just proximal of the hand.

5- The sling is removed every 2 hours to check for circulationand skin integrity.