Ch. 32 Skin Integrity WK4 Quiz

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Fundamentals II

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Ch. 32 Skin Integrity WK4 Quiz


Ch. 32 Skin Integrity WK4 QuizVersión en línea Fundamentals II por Grace&Grit 1 A nurse is assessing an older adult client with limited mobility and poor nutritional intake. Which factor places this client at greatest risk for impaired skin integrity? a Use of antihypertensive medication b Presence of hyperpigmentation c Decreased sensation in lower extremities d History of frequent bathing 2 A client has a surgical wound with approximated edges and minimal drainage. Which type of healing is occurring? a Secondary intention b Tertiary intention c Primary intention d Regeneration 3 A nurse observes yellow drainage containing pus and streaks of blood from a client’s wound. How should this be documented? a Serous b Sanguineous c Purulent d Purosanguineous 4 Which nursing intervention is most effective in preventing pressure injuries in a bedbound client? a Applying heat to pressure points b Using transparent film dressings c Repositioning the client every 2 hours d Administering vitamin supplements 5 Which task can the nurse delegate to unlicensed assistive personnel (UAP)? a Initial wound assessment b Wound irrigation with saline c Evaluating wound healing progress d Turning and repositioning the client 6 A nurse observes a shallow open ulcer with a red-pink wound bed and no slough. Which pressure injury stage should be documented? a Stage I b Stage II c Stage III d Unstageable 7 Which nutrient is most essential for collagen synthesis and wound healing? a Vitamin D b Calcium c Vitamin C d Iron 8 Which finding indicates a localized wound infection? a Warmth and swelling around the wound b Pale wound edges c Increased serous drainage d Decreased pain at the site 9 A nurse notices a colleague documenting wound care they did not perform. What is the nurse’s best initial action? a Confront the colleague publicly b Report to the charge nurse c Document the discrepancy in the client’s chart d Ignore the situation 10 A client presents with a dry, black eschar on the heel. What is the most appropriate nursing action? a Irrigate with saline b Remove the eschar with sterile scissors c Apply a moist dressing d Leave the wound covered and consult wound care 11 Which of the following increase a client’s risk for pressure injuries? Select all that apply. Choose one or more answers a Immobility b Poor nutrition c Excessive moisture d High sensory perception e Advanced age 12 Which nursing interventions support optimal wound healing? Select all that apply. Choose one or more answers a Maintain a moist wound environment b Administer prescribed antibiotics c Encourage protein-rich diet d Use alcohol-based cleansers e Monitor blood glucose levels 13 Which are appropriate documentation practices for wound care? Choose one or more answers a Describe wound size and drainage b Use vague terms like “looks bad” c Record dressing type and time applied d Note patient’s pain level during care e Include subjective impressions 14 Which tasks can be delegated to unlicensed assistive personnel (UAP)? Choose one or more answers a Repositioning the client b Applying sterile dressings c Assisting with hygiene d Reporting skin redness e Performing wound assessment 15 Which findings suggest a wound is healing properly? Choose one or more answers a Granulation tissue formation b Decreased drainage c Increased pain d Reduction in wound size e Foul odor Feedback 2 Primary intention involves clean incisions with edges that are approximated, leading to minimal scarring. 9 Reporting to a supervisor upholds ethical standards and protects patient safety. 12 Use alcohol-based cleansers → not recommended, because they dry tissue and delay healing. 13 Documentation should be objective, specific, and clinically relevant. 14 UAPs can observe and report but cannot perform sterile procedures or assessments. 15 Increased pain and foul odor may indicate complications.

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Ch. 32 Skin Integrity WK4 Quiz

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Ch. 32 Skin Integrity WK4 QuizVersión en línea

por Grace&Grit

A nurse is assessing an older adult client with limited mobility and poor nutritional intake. Which factor places this client at greatest risk for impaired skin integrity?

A client has a surgical wound with approximated edges and minimal drainage. Which type of healing is occurring?

A nurse observes yellow drainage containing pus and streaks of blood from a client’s wound. How should this be documented?

Which nursing intervention is most effective in preventing pressure injuries in a bedbound client?

Which task can the nurse delegate to unlicensed assistive personnel (UAP)?

A nurse observes a shallow open ulcer with a red-pink wound bed and no slough. Which pressure injury stage should be documented?

Which nutrient is most essential for collagen synthesis and wound healing?

Which finding indicates a localized wound infection?

A nurse notices a colleague documenting wound care they did not perform. What is the nurse’s best initial action?

A client presents with a dry, black eschar on the heel. What is the most appropriate nursing action?

Which of the following increase a client’s risk for pressure injuries? Select all that apply.

Choose one or more answers

Which nursing interventions support optimal wound healing? Select all that apply.

Choose one or more answers

Which are appropriate documentation practices for wound care?

Choose one or more answers

Which tasks can be delegated to unlicensed assistive personnel (UAP)?

Choose one or more answers

Which findings suggest a wound is healing properly?

Choose one or more answers

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