Review Practice Exercise 3

Skin integrity and wound healing > Fundamentals

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Practice Exercise 3

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Total Questions : 5

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Question 1:

Medical adhesives, such as tape securing a wound dressing, cause Medical Adhesive–Related Skin Injury (MARSI). Which of the following interventions reduce the risk for MARSI? Select all that apply

A. Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound. B. Change dressing only when saturated. C. Apply adhesive remover. D. Use Montgomery ties to secure the dressing. E. Immobilize area of wound.

Answer and Explanation

Choice A:

Gently loosen and remove tape parallel to the skin: This technique minimizes trauma to the epidermis by reducing shear and tension on the skin surface during tape removal. Pulling tape away from the skin increases the risk of skin stripping, leading to MARSI (Medical Adhesive–Related Skin Injury).

Choice B:

Change dressing only when saturated: Waiting until a dressing is saturated increases moisture exposure, which weakens skin integrity and promotes maceration-raising MARSI risk. Dressings should be changed per schedule or when compromised.

Choice C:

Apply adhesive remover: Adhesive removers help dissolve adhesive residue and allow for gentle tape removal, reducing the risk of epidermal stripping or skin tears.

Choice D:

Use Montgomery ties to secure dressing: Montgomery ties reduce the need for repeated tape removal on the skin, thus preventing irritation and breakdown associated with frequent dressing changes.

Choice E:

Immobilize area of wound: Immobilizing a wound site is not directly related to MARSI prevention. It may even hinder mobility and circulation, delaying healing.

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Question 2:

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?

A. Alginate B. Dry gauze C. Hydrocolloid D. No dressing is indicated

Answer and Explanation

Choice A:

Alginate: Alginate dressings are designed for moderate to heavy exudate and deeper wounds, as they absorb large amounts of drainage. They are not appropriate for shallow, partial-thickness ulcers with minimal exudate.

Choice B:

Dry gauze: Dry gauze can adhere to the wound bed and damage granulation tissue upon removal. It does not maintain a moist environment, which is essential for healing of partial-thickness wounds.

Choice C:

Hydrocolloid: Hydrocolloid dressings maintain a moist wound environment, promote autolytic debridement, and protect the wound from contamination. They are ideal for partial-thickness, shallow pressure ulcers without necrosis or heavy exudate.

Choice D:

No dressing is indicated: Leaving the wound uncovered exposes it to friction, contamination, and drying. All pressure ulcers, even shallow ones, require protective coverage to promote healing.

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Question 3:

Which of the following are measures to reduce tissue damage from shear? Select all that apply

A. Use a transfer device (e.g., transfer board). B. Have head of bed elevated when transferring patient. C. Have head of bed flat when repositioning patient. D. Raise head of bed 60 degrees when patient is positioned supine. E. Raise head of bed 30 degrees when patient is positioned supine.

Answer and Explanation

Choice A:

Use a transfer device (e.g., transfer board): Transfer devices minimize friction and shear by allowing smooth movement instead of dragging skin against bed linens.

Choice B:

Have head of bed elevated when transferring patient: Elevating the head of bed during transfer increases shear forces because the body slides down while the skin adheres to the surface.

Choice C:

Have head of bed flat when repositioning patient: Keeping the bed flat reduces sliding and skin stretching, minimizing shear during repositioning.

Choice D:

Raise head of bed 60 degrees when patient is positioned supine: A high Fowler’s position (>45°) increases downward sliding and shear over the sacrum and coccyx.

Choice E:

Raise head of bed 30 degrees when patient is positioned supine: A semi-Fowler’s position (~30°) balances respiratory comfort with reduced shear risk; this is the recommended position for most immobile patients.

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Question 4:

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? Select all that apply

A. Frequent position changes B. Keeping the buttocks exposed to air at all times C. Using a large absorbent diaper, changing when saturated D. Using an incontinence cleaner E. Applying a moisture barrier ointment

Answer and Explanation

Choice A:

Frequent position changes: Repositioning decreases prolonged exposure of skin to moisture and pressure, promoting circulation and preventing skin breakdown.

Choice B:

Keeping the buttocks exposed to air at all times: While brief air exposure during cleansing and drying can help, keeping the area exposed “at all times” risks chilling, contamination, and infection.

Choice C:

Using a large absorbent diaper, changing when saturated: Diapers trap moisture and heat, increasing the risk of maceration and pressure injuries. Skin should be kept clean and dry, not enclosed in moisture-retaining materials.

Choice D:

Using an incontinence cleaner: pH-balanced, no-rinse cleansers are gentler than soap and water. They remove urine and feces effectively without damaging the skin’s protective barrier.

Choice E:

Applying a moisture barrier ointment: Moisture barriers (e.g., zinc oxide or dimethicone-based creams) protect skin from irritants and moisture, reducing the risk of dermatitis and pressure injury.

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Question 5:

Which action would be a priority in preventing a patient from developing a pressure ulcer?

A. Using waterproof material on the bed B. Massaging any reddened area frequently C. Using an air-inflated ring to relieve pressure on areas D. Using a mild cleansing agent when cleansing the skin

Answer and Explanation

Choice A:

Using waterproof material on the bed: Waterproof materials trap moisture and heat, increasing friction and maceration, which can lead to skin breakdown. Breathable materials are preferred.

Choice B:

Massaging any reddened area frequently: Massaging reddened areas can damage fragile capillaries in compromised skin, worsening tissue injury rather than preventing it.

Choice C:

Using an air-inflated ring to relieve pressure on areas: Air rings (donuts) can actually increase localized pressure and impair circulation to surrounding tissues, making ulcers more likely.

Choice D:

Using a mild cleansing agent when cleansing the skin: Gentle cleansing prevents skin irritation and maintains integrity, reducing the risk of skin breakdown. Harsh soaps strip natural oils and increase dryness and friction, predisposing the skin to pressure injury.

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Practice Exercise 3

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