Review Practice Exercise 1

Skin integrity and wound healing > Fundamentals

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Practice Exercise 1

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Total Questions : 5

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Question 1:

Which of the following are primary risk factors for pressure ulcers? Select all that apply

A. Low-protein diet B. Insomnia C. Lengthy surgical procedures D. Fever E. Sleeping on a waterbed

Answer and Explanation

Choice A:

Low-protein diet: Protein is essential for tissue repair and skin integrity. Malnutrition and a low-protein diet cause decreased collagen formation and slower wound healing, making skin more prone to breakdown and ulceration.

Choice B:

Insomnia: While lack of sleep may affect general health, it does not directly cause pressure ulcers. Pressure ulcers are caused primarily by prolonged pressure, friction, shear, and poor nutrition-not by sleep disturbances.

Choice C:

Lengthy surgical procedures: Clients undergoing long surgeries are immobile for extended periods, which leads to sustained pressure on bony prominences and impaired tissue perfusion, a major risk factor for pressure ulcer development.

Choice D:

Fever: Fever increases metabolic demands and causes sweating, leading to moisture and skin maceration. It also increases tissue oxygen consumption, which can predispose skin to breakdown if perfusion is compromised.

Choice E:

Sleeping on a waterbed: A waterbed actually helps distribute pressure more evenly, reducing the risk of pressure ulcers. It can be beneficial for clients at risk, as it minimizes localized pressure points.

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Question 2:

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

A. Serous B. Sanguineous C. Serosanguineous D. Purulent

Answer and Explanation

Choice A:

Serous: Serous drainage is thin, clear to pale yellow - like plasma - and is not odorous or green.

Choice B:

Sanguineous: Sanguineous drainage is fresh blood - bright red - indicating active bleeding; not thick, odorous, or green.

Choice C:

Serosanguineous: Serosanguineous is a thin, pinkish mixture of serous fluid and a small amount of blood. It’s not typically thick, malodorous, or green.

Choice D:

Purulent: Purulent drainage is thick, often discolored (yellow, green), and frequently malodorous - it usually indicates the presence of pus and infection (neutrophils, bacteria, necrotic debris).

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Question 3:

Your client has a Braden scale score of 17. Which is the appropriate nursing action?

A. Assess the client again in 24 hours; the score is within normal limits. B. Implement a turning schedule; the client is at increased risk of skin breakdown. C. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown. D. Request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown.

Answer and Explanation

Choice A:

Assess the client again in 24 hours; the score is within normal limits: A Braden Scale score of 17 indicates mild risk for pressure ulcer development, not normal limits. Normal (no risk) is a score of 19–23. Therefore, waiting 24 hours without intervention could lead to preventable skin breakdown.

Choice B:

Implement a turning schedule; the client is at increased risk of skin breakdown: A score of 15–18 indicates mild risk, so preventive interventions are required. The nurse should implement frequent repositioning (every 2 hours), encourage mobility, and keep the skin clean and dry to reduce pressure and moisture-related damage.

Choice C:

Apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown: A Braden score of 17 does not reflect moderate risk (which is 13–14). Applying a transparent film may be appropriate for existing wounds or higher-risk clients, but at this score, repositioning and skin inspection are more appropriate interventions.

Choice D:

Request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown: A very high risk category applies to scores ≤9. Specialized beds are used for clients at very high or high risk (≤12). This intervention would be unnecessary and not cost-effective for a client scoring 17.

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Question 4:

After an initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, at what stage would this ulcer be classified?

A. Stage I B. Stage II C. Stage III D. Stage IV

Answer and Explanation

Choice A:

Stage I is non-blanchable erythema of intact skin (redness that doesn’t blanche) but the skin is still intact and there is no blistering or partial-thickness loss.

Choice B:

Stage II describes partial-thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed, or as an intact or open/ruptured serum-filled blister. A reddened area that has blistered fits the Stage II definition.

Choice C:

Stage III indicates full-thickness skin loss with damage or necrosis of subcutaneous tissue that may extend down to (but not through) underlying fascia; you would see deeper tissue loss, possibly fat, not just a superficial blister.

Choice D:

Stage IV is full-thickness tissue loss with exposed bone, tendon, or muscle and often extensive necrosis or damage - far deeper and more severe than a blistered reddened area.

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Question 5:

Which type of wound closes by primary intention?

A. Second-degree burn B. Pressure ulcer C. Traumatic injury D. Surgical incision

Answer and Explanation

Choice A:

Second-degree burn: Burns heal by secondary intention, involving tissue regeneration and scar formation due to partial-thickness loss.

Choice B:

Pressure ulcer: Heals by secondary or tertiary intention, depending on depth and infection status, since wound edges cannot be easily approximated.

Choice C:

Traumatic injury: Usually heals by secondary or tertiary intention, depending on tissue loss and contamination.

Choice D:

Surgical incision: Surgical wounds are clean and closed with sutures or staples, allowing the wound edges to approximate directly. Healing occurs quickly with minimal scar formation.

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Practice Exercise 1

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