Review Assessment of Skin Integrity and Wound Characteristics

Skin integrity and Basic wound care and dressing changes > Fundamentals

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Assessment of Skin Integrity and Wound Characteristics

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Total Questions : 3

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Question 1:

A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?

A. Serous drainage from the wound B. Erythema around the wound edges C. Foul odor from the wound D. Granulation tissue in the wound bed

Answer and Explanation

Choice A:

This is a normal finding, as serous drainage is clear and watery and indicates fluid leakage from damaged capillaries.

Choice B:

This is a normal finding, as erythema (redness) around the wound edges indicates inflammation and increased blood flow to the area, which are part of the normal healing process.

Choice C:

Rationale: Foul odor from the wound may indicate an infection or necrotic tissue, which can impair wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture if indicated.

Choice D:

This is a normal finding, as granulation tissue is pink or red and indicates new tissue growth and blood vessel formation in the wound.

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Question 2:

A client is admitted to the hospital with a burn injury covering 30% of the body surface area. The nurse anticipates that the client will require which type of dressing for wound care?

A. Hydrocolloid dressing B. Hydrogel dressing C. Alginate dressing D. Silver dressing

Answer and Explanation

Choice A:

This is a type of occlusive dressing that forms a gel-like substance when in contact with wound exudate. Hydrocolloid dressing can promote moist wound healing, reduce pain, and protect the wound from contamination. However, it is not suitable for infected wounds or wounds with heavy drainage, as it can trap bacteria and fluid in the wound and cause maceration of the surrounding skin.

Choice B:

This is a type of dressing that contains water or glycerin and provides moisture to dry wounds. Hydrogel dressing can hydrate necrotic tissue, reduce pain, and facilitate autolytic debridement. However, it is not suitable for wounds with heavy drainage, as it can increase fluid loss and cause maceration of the surrounding skin.

Choice C:

This is a type of dressing that contains seaweed fibers and forms a gel-like substance when in contact with wound exudate. Alginate dressing can absorb large amounts of fluid, fill dead space in the wound, and facilitate hemostasis. However, it is not suitable for dry wounds or wounds with minimal drainage, as it can dehydrate the wound and cause trauma to granulation tissue when removed.

Choice D:

Rationale: Silver dressing is a type of antimicrobial dressing that contains silver ions, which have bactericidal properties and can prevent or treat wound infections. Silver dressing can also reduce pain, inflammation, and odor from the wound. Silver dressing is often used for burn injuries, as they are at high risk of infection due to loss of skin integrity and exposure to pathogens.

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Question 3:

A nurse is evaluating a client's response to negative pressure wound therapy (NPWT). Which outcome indicates that the therapy is effective?

A. Decreased edema in the wound area B. Increased drainage from the wound C. Decreased granulation tissue in the wound bed D. Increased eschar formation on the wound surface

Answer and Explanation

Choice A:

Rationale: Decreased edema in the wound area indicates that NPWT is effective, as NPWT applies negative pressure (suction) to the wound, which removes excess fluid, reduces swelling, and improves blood circulation to the area

Choice B:

This indicates that NPWT is ineffective, as NPWT should reduce drainage from the wound by removing excess fluid and promoting wound closure.

Choice C:

This indicates that NPWT is ineffective, as NPWT should increase granulation tissue in the wound bed by stimulating cell proliferation and angiogenesis.

Choice D:

This indicates that NPWT is ineffective, as NPWT should decrease eschar formation on the wound surface by facilitating debridement and removing necrotic tissue.

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Total Questions : 3

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Assessment of Skin Integrity and Wound Characteristics

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