Tissue Integrity Test 6 Practice

These questions are part of the practice quiz. Start practicing

• Which action helps prevent maceration around a wound?
• A dressing is prescribed to facilitate autolytic debridement. Which nursing action indicates effectiveness?
• Which topical measure helps protect surrounding skin from moisture in a pressure ulcer?
• Which statement is appropriate for preventing wound infection in home care?
• Which equipment is appropriate for irrigating a surgical wound?
• Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated?
• Which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure ulceration?
• Which nutrient supports healing by promoting wound closure?
• Which of the following can be used to clean a granulating wound?
• What is the most important nursing intervention for a patient who has impaired physical mobility related to incisional pain?
• Which statement about skin anatomy is true?
• Which option is not listed as a topical agent for cleaning highly colonized wounds?
• Which statement about the Braden Scale is true?
• Which statement indicates understanding of the disadvantages of using dry applications for wound therapy?
• Which nursing action indicates a need for further learning when repositioning a patient to reduce the risk of pressure ulcers?
• Which intervention is part of the NIC wound care?
• What is one function of black polyurethane foam dressing in wound management?
• Tetanus antitoxin injection is necessary unless the last shot was administered within the past ____ years.
• To measure undermining depth, which tool is used?
• Which statement about aging skin is true?
• Which statement indicates effective learning by the nursing student in home care for preventing pressure ulcers?
• Which characteristic is expected when using a hydrogel dressing?
• A patient developed a pressure ulcer that is deep with exudates. Which type of dressing is provided to the patient?
• Which of the following is NOT a listed purpose served by dry gauze dressing?
• Which statement is true regarding hydrogel dressings?
• In primary-intention wound healing, which statement accurately describes the process?
• Serosanguineous drainage is described as which of the following?
• Which step begins the wound irrigation sequence?
• Which nursing intervention is appropriate for a patient at risk of infection due to a surgical incision at the right hip?
• Which fluid, when exposed to skin, poses the highest risk for skin breakdown?
• Which statement about nonblanchable erythema is true?
• Which finding is characteristic of abnormal healing of a wound closed primarily?
• Which dressing should the nurse use to protect and absorb moisture when caring for a pressure ulcer?
• Which statement about cold application is true?
• Which type of dressing is used for stage I pressure ulcers?
• Autolytic debridement relies on which mechanism?
• If a patient using negative-pressure wound therapy (NPWT) reports severe pain, which intervention is most appropriate?
• Which piece of knowledge does a nurse not require for assessing a patient's risk for developing pressure ulcers?
• When removing tape from the skin during wound care, which step should be performed first?
• When collecting samples of wound drainage for culture, which action indicates a need for further learning?
• Which factor does not put a patient at risk for burns during heat therapy?
• To reduce the risk of developing pressure ulcers, which action is most effective during patient care?
• Which type of wound drainage is clear and watery?
• Negative-pressure wound therapy is most appropriately considered for which type of wound?
• Which step is performed after allowing solution to flow over the wound in the irrigation sequence?
• In a supine position, which site is not at risk for a pressure ulcer?
• Which dressing is commonly used to secure a wound and may involve Montgomery ties?
• After the dressing is removed, which step comes next?
• For a patient diagnosed with venous stasis ulcers, which support surface should the nurse anticipate for this patient?
• Which finding most strongly suggests infection in a wound?
• Which practice helps prevent infection during a dressing change?
• Which statement best describes a method to avoid contamination when cleaning around a wound drain?
• Which statement is true regarding sutures?
• Which measure supports preventing pressure ulcer formation in patients with limited mobility by reducing tissue loading?
• Which nutrient is recognized as an essential antioxidant that promotes wound healing?
• Which intervention is part of the nursing intervention classification (NIC) for pressure management care?
• Which dressing is most appropriate for absorbing moderate to heavy exudate from a pressure ulcer?
• Which device is commonly used to help redistribute pressure for stage III–IV ulcers?
• When performing any wound care procedure, which nursing action is appropriate for addressing the patient's pain and discomfort?
• Which layer of the skin is primarily responsible for producing collagen and providing tensile strength?
• Which type of wound drainage is pus-containing?
• In an abdominal wound with evisceration, the nursing action of placing sterile saline-soaked gauze over exposed tissues is primarily to:
• For exudate management in the periwound area, which intervention is appropriate?
• What syringe size is used for irrigating an open wound?
• A patient at very high risk of pressure ulcer development on the Braden Scale would have which score?
• What is the third step in the dressing removal sequence?
• What tool is typically used to deliver saline during wound irrigation?
• Reviewing the primary health care provider’s orders for negative-pressure wound therapy (NPWT) settings involves which step of the nursing process?
• Which action is appropriate when cleaning the area around a drain site?
• Which step demonstrates sterile technique during wound irrigation?
• Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility?
• What is the daily retinol equivalent range for vitamin A recommended to support wound healing?
• If a patient has black wound tissue during wound assessment, in which stage is the pressure ulcer most likely categorized?
• Which action is appropriate when a wound has underlying organs protruding through the dressing?
• On which postoperative day did redness and tan-colored, foul-smelling drainage appear from the incision?
• Which action helps minimize maceration by reducing moisture exposure to the wound?
• Which dressing is used for a patient with a clean stage III pressure ulcer?
• Stage II ulcers involve which type of tissue loss?
• In a patient with a moist-to-dry dressing showing increased wound drainage, what is the immediate nursing intervention?
• What is an advantage of a moist application in wound healing?
• Which blood cells are known as garbage cells?
• Which statement about nutrition and wound healing is correct?
• Which nutrient deficiency may impair the inflammatory response in wound healing?
• Which of the following is NOT among the interventions listed to minimize risk for pressure ulcers?
• An elastic net is used as an additional dressing on a patient's leg. What is the primary rationale?
• When collecting wound drainage samples for culture, which practice is inappropriate?
• Which practice supports infection control during wound care?
• Which nursing intervention is appropriate for reducing the risk of skin breakdown in an immobile patient?
• Which statement about liquid skin barriers is true?
• Which statement describes protective positioning for the sacrum and coccyx to prevent pressure and shear?
• Which cells are known as garbage cells in the wound healing process?
• Which dressing is inappropriate for a patient with a clean stage II pressure ulcer?
• Which description best matches serosanguineous drainage?
• Which nutrient is an antioxidant that promotes wound healing?
• A wound drainage appears thick and yellow. Which type is this?
• Before performing a dressing change, which factor should be assessed to manage patient comfort?
• A patient's wound drainage appears thick and yellow. Which type of drainage is this considered?
• Which dressing is commonly used to absorb exudate from a pressure ulcer while protecting surrounding tissue?
• What is the first step in the correct wound irrigation sequence?
• If there is increased wound drainage with a moist-to-dry dressing, what is the immediate nursing action?
• Calcium alginate dressings are used to manage serous leakage.
• What is the primary purpose of the Braden Scale?
• How is nursing care for a patient who has a stage IV pressure ulcer different from that for a patient who has a stage I pressure ulcer?
• Which nursing action can help facilitate faster healing of a slow-healing ulcer?
• A patient who had debriding enzymes applied to an ulcer region reports a burning sensation. Which nursing action most likely caused this?
• According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer?
• Arrange the steps in the correct order for wound irrigation.
• Which dressing is commonly used to protect periwound skin while providing a moist environment?
• Which dietary statement is true for a patient with pressure ulcers?
• Which action provides comfort in the care plan for a coccyx pressure ulcer?
• Which dressing is appropriate for a Stage I pressure ulcer?
• Which daily fluid intake per kilogram is recommended for proper wound healing?
• Which type of wound drainage is sanguineous?
• To help maintain an airtight seal for negative-pressure wound therapy, which action is recommended?
• Which equipment is used by the primary health care provider when applying a moist dressing to a pressure ulcer?
• Why is an elastic net used as an additional dressing on a patient's leg?
• How many subscales are in the Braden Scale?
• Which nutrient supports healing by promoting wound closure?
• Which of the following is part of NIC wound care?
• Which nutrient supports healing by promoting wound closure?
• For an acute wound due to trauma in the emergency department, which nursing action is the priority in wound care?
• Which action would be inappropriate when removing the NWPT dressing to minimize tissue damage?
• Which factor is most commonly associated with chronic wounds?
• Which fluid is least likely described as posing a high risk for skin breakdown when exposed to skin?
• Which action is appropriate when providing care to a patient who exhibits no risk for skin breakdown?
• Which suture type is designed to provide extra strength for high-tension wounds?
• The nurse is reviewing the dressing change procedure for a patient with pressure ulcers. What is the rationale behind this action?
• In a postoperative hip incision patient who needs assistance turning, which intervention should the nurse avoid?
• What intervention should the nurse plan for a patient who has a sacral pressure ulcer?
• Which intervention is part of the nursing intervention classification (NIC) for wound care?
• Which statement indicates the need for further learning about wound dressings?
• What is the total score range for the Braden Scale?
• Which pressure ulcer site is found immediately distal to the buttock?
• Which stage of the pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough?
• Which statement about dry dressings is true?
• What amount of zinc is recommended for wound healing?
• When serous leakage is observed from an ulcer dressing, which topical agent should be used?
• Which step helps protect the bed from irrigation solution?
• Which action is performed immediately before removing the gloves in the wound irrigation sequence?
• What action should the nurse take when removing a dressing from an older adult patient?
• Which equipment is used by the primary health care provider when applying a moist dressing to a patient with pressure ulcers?
• Which statement about the purposes of wound dressings is true?
• Which statement about skin layers is correct?
• Which type of wound drainage is pale yellow and watery?
• According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer?
• Which action is NOT recommended when removing tape from the skin?
• During dressing changes for a dime-sized ulcer under adhesive tape, which should be used to secure the wound?
• Which statement indicates the need for further teaching about aging skin?
• Which is characteristic of abnormal healing in a secondary-intention wound?
• A quarter-sized blanchable area over the sacral area is observed. This finding is most likely due to which factor?
• After knee surgery causing a pressure ulcer due to bed restriction, which irrigating fluid should be used to clean the ulcer?
• Arrange the events that occur during the proliferative phase of wound healing in chronological order.
• In a care plan for a patient with a coccyx pressure ulcer, which component helps provide comfort?
• How many calories per kilogram per day should the nurse suggest to promote proper wound healing?
• What step is a component of the planning phase for a patient who has impaired skin integrity?
• A wound with tissue that is too dark to assess the base is categorized as which stage?
• During a dressing change, the patient begins to bleed. Which action is the most appropriate first step to manage the bleeding?
• A patient with diabetes and limited mobility has intact skin. Which nursing intervention should the nurse provide to help prevent skin breakdown?
• Which statement best describes aging skin vulnerability?
• Which intervention is part of the nursing intervention classification (NIC) for pressure management?
• In caring for a patient with a chronic wound showing exudate around the wound margins, which intervention is most appropriate?
• The health care provider prescribes a dressing that will facilitate autolytic debridement. Which action by the nurse indicates effective nursing?
• What amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing?
• Which nursing action during removing tape from the patient's skin during wound care requires correction?
• Before removing the dressing and addressing a pressure ulcer, which step should be performed first?
• Which statement is true regarding hydrogel dressings?
• Which practice supports moist wound healing?
• Which practice helps manage a wound with heavy exudate by increasing absorbency of the dressing material?
• Which statement about the Braden Scale is true?
• A pressure ulcer with full-thickness skin loss and exposure of subcutaneous tissue is categorized as which stage?
• Which action is not appropriate when cleaning an exudating wound?
• During negative-pressure wound therapy near the knee joint, which nursing action indicates the need for further learning?
• Which of the following is not indicated to manage maceration of the periwound skin?
• For an immobile patient at high risk for impaired skin integrity, which plan component is most appropriate?
• Which type of dressing is recommended for a stage I pressure ulcer?
• Which term describes a location near the center of the body?
• Which finding indicates abnormal healing in a wound closed by primary intention?
• What is the purpose of using a waterproof underpad when applying a moist dressing to a patient with pressure ulcers?
• In wound healing, which statement about nutrients is correct?
• Which step directly follows placing the waterproof pad in the wound irrigation sequence?
• When a patient reports sensation under the dressing, which nursing action is most appropriate?
• Which type of support surface is indicated for stage IV pressure ulcers?
• Which factor increases the risk for injury when applying heat therapy to a wound for a pediatric patient?
• Which intervention is appropriate for managing periwound exudate in a chronic wound?
• Which nursing intervention would have prevented the pressure ulcer in a patient who recently had hip replacement surgery?
• Which of the following is a characteristic of a Stage I pressure ulcer?
• What is the rationale for cleaning a wound with normal saline using an irrigating syringe?
• Which nursing action during negative-pressure wound therapy on the forearm contributed to the elbow pressure ulcers?
• Which statement about healing of a surgical incision is true?
• Which nursing interventions are appropriate for a patient who is at risk for pressure ulcer development due to impaired mobility or friction and shear?
• What is the role of vitamin A in wound healing?
• Which statement best describes the goal of using a moist dressing in wound care?
• Arrange the steps for preparing an ice bag in the correct order.
• Which of the following steps is appropriate immediately after a patient presents with evisceration?
• What is the purpose of the NPWT foam dressing?
• Which of the following is NOT an advantage of using dry wound applications?
• Which nutrient is associated with promoting wound closure?
• Which task can be delegated to nursing assistive personnel (NAP) in caring for a patient with a pressure ulcer?
• What does nonblanchable erythema indicate about the skin?
• Which intervention is most appropriate to protect periwound skin from maceration?
• During a dressing change after a cesarean section, which action indicates a need for further learning?
• When cleaning a wound, which action is incorrect?
• Which nutrient is most directly linked to collagen synthesis during wound healing?
• A patient with a sacral pressure ulcer; to reduce infection risk, which intervention is appropriate?
• Nonblanchable erythema indicates what about the skin?
• What is the primary purpose of using a dry gauze dressing in wound care?
• Which statement describes the purpose of applying a liquid skin barrier on periwound skin?
• Which nutrient supports healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis?
• Which drainage type is thin, watery, and clear?
• Which tool is used to evaluate wound healing in pressure ulcers?
• Which dressing creates a moist environment to promote healing?
• Which skin finding is an early sign of pressure injury that may heal with relief of pressure?
• Which dressing is appropriate for a patient with a clean stage II pressure ulcer?
• Which action is NOT appropriate to minimize pain during wound care?
• For a dry wound, which dressing is preferred?
• Which type of wound drainage is serosanguineous?
• Black polyurethane foam dressing has a property that helps determine wound depth. Which statement describes that property?
• Which action requires correction when removing tape from fragile skin?
• Which action is performed first when preparing to obtain a wound culture by needle aspiration?
• Which term describes a location away from the center of the body?
• Which drainage description is most indicative of wound infection in the described case?
• For a patient whose Braden Scale score is 16, indicating risk of skin breakdown, which nursing intervention is most appropriate to reduce risk?
• A patient with an abdominal wound from a motor vehicle accident comes into the emergency room with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. What is the rationale for this action?
• Which action supports proper technique when applying negative-pressure wound therapy near a knee wound?
• If a patient on NPWT reports severe pain, which action is most appropriate?
• Which dressing is most associated with promoting autolytic debridement?
• Which description corresponds to sanguineous drainage?
• Which action corresponds to the second step in the dressing removal process?
• Which action would minimize pain during tape removal?
• During wound assessment, measuring the length and width of a pressure ulcer serves what purpose?
• Which dressing is typically chosen for a wound that is not healing and requires careful moisture management, as reflected in practice for wound care?
• A patient has reddened periwound tissue, foul drainage, and open areas near the staples. What is the most likely nursing diagnosis?
• Which measurements are typically documented for a wound assessment?
• Which pressure ulcer stage is expected to heal through granulation and reepithelialization?
• In preparing to treat a pressure ulcer, which action is performed first?
• Which action provides comfort for a patient with a coccyx pressure ulcer?
• Which statement is true regarding stage III pressure ulcers?
• What quantity of vitamin C is recommended for wound healing? Record your answer using a whole number.
• Which dressing is specifically described as preferred for dry wounds?
• Which site is found immediately distal to the buttock and is a common site for pressure ulcers?
• Arrange the steps for preparing an ice bag in the correct order.
• For advanced pressure ulcers, which surgical-related intervention could be considered?
• Which type of wound drainage is purulent?
• Which intervention is not necessary for a patient who has impaired skin integrity related to limited mobility?
• Maceration of the skin is most closely associated with which wound care factor?
• While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer?
• Which type of wound drainage is serous?
• Nonblanchable erythema on intact skin is commonly considered an early sign of a pressure injury.
• Which statement best describes why a hydrocolloid dressing may be used for moderate deep dermal ulcers?
• Which statement about dressings is NOT true?
• For a dry wound, which type of dressing is preferred?
• To protect periwound skin from moisture during wound care, which product is commonly used?
• On the Braden Scale, which statement is true?
• Which measure is appropriate to support skin integrity in incontinent patients?
• A pressure ulcer that can be dressed with a transparent or hydrocolloid dressing is at which stage?
• When maceration of periwound skin is observed, which action should be communicated to the primary health care provider?
• In a chronic wound with periwound exudate, which intervention is appropriate?
• Which wound cleansing method reduces infection risk?
• After negative suction wound therapy, the patient reports severe pain. What is the immediate nursing action?
• The nurse is caring for a pressure ulcer that is covered in eschar. Which dressing prescription will the nurse use?
• Which is an advantage of using a hydrogel dressing?
• Which term best describes a location near the center of the body?
• Which statement indicates understanding of the disadvantages of using moist applications for wound therapy?
• Which surface type should be used to reduce pressure injuries in immobile patients?
• Which intervention is associated with pressure management in NIC?
• For advanced ulcers requiring surgical consideration, which intervention is specifically appropriate?
• Which action is involved in safely removing retention sutures?
• Which nursing intervention is appropriate for a patient at risk for skin breakdown due to poor dietary intake?
• What amount of protein per kilogram of body weight a day should the nurse recommend to support wound healing?
• Which patient scenario represents a higher risk for developing pressure ulcers?
• In a patient with a pressure ulcer and macerated periwound skin, which nursing intervention is most appropriate to manage the condition?
• During the proliferative phase, which process occurs last?
• Which statement best describes the use of a hydrocolloid dressing for moderate deep dermal ulcers?
• Which adjuvant treatment is considered for advanced pressure ulcers requiring surgical consideration?
• Which surface reduces pressure on vulnerable areas in immobile patients?
• Reviewing orders for negative-pressure wound therapy (NPWT) to a patient, which nursing process step is involved?
• A patient with a stage III pressure ulcer develops a fever of 103°F, and purulent discharge with odor from the wound. What is most likely occurring?
• Which type of support surface should the nurse plan to use to treat and prevent complications associated with immobility, such as pulmonary issues, venous stasis, and urinary problems?
• Which option best supports healing of pressure ulcers by addressing nutrition?
• On the Braden Scale, a score of 8 corresponds to which level of risk?
• Which action helps prevent heel breakdown in a patient with stage III–IV ulcers?