Wound Care Quiz

What type of wound is a superficial abrasion classified as?

Partial thickness.

What is the priority nursing intervention for a patient with a new Stage I pressure injury on their heel?

Initiate a turning and repositioning schedule and offload the heel.

Which interventions should be implemented to prevent skin tears in geriatric patients?

Use gentle cleaning techniques with water or a cleansing agent, keep the skin moisturized, and protect fragile skin with gauze.

True or False: Skin integrity is solely determined by genetic factors.

False.

What is the initial nursing action for a surgical dressing change ordered for a post-operative patient?

Perform proper handwashing.

Which factors can increase a patient's risk of skin breakdown?

Poor hygiene practices and obesity.

What is the correct order of the phases of normal wound healing?

Hemostasis, Inflammation, Proliferation, Maturation.

True or False: A Stage III pressure injury involves full-thickness skin loss with exposed bone, tendon, or muscle.

False.

What is the term for the soft, dead tissue that covers a wound bed and is yellow in color?

Slough.

What is the primary purpose of a wound vacuum therapy (NPWT) device?

To increase vascularity, reduce edema, and remove exudate.

True or False: When documenting a pressure injury, the staging should be recorded even if you are unsure of the correct stage.

False.

How do venous ulcers typically appear?

Wet, large, and irregular with edema.

What characterizes unstageable pressure injuries?

The true depth of the wound cannot be seen due to slough or eschar.

True or False: Maintaining a moist wound bed is generally recommended for most types of wounds to promote healing.

True.

What type of dressing would be most appropriate for a heavily exudating wound?

Alginate dressing.

What is the first action a nurse should take if they observe non-blanchable erythema on a patient's coccyx?

Reposition the patient and offload pressure from the coccyx.

True or False: Heat therapy is generally recommended for the initial management of direct trauma.

False.

What assessment findings might suggest a potential infection in a surgical wound?

Increased pain at the wound site, erythema and edema around the wound edges, and elevated body temperature.

What should a caregiver be educated on regarding skin integrity for a patient being discharged with a healing wound?

The importance of yearly UV skin checks and sunscreen use.

True or False: A wound that has healed will have the same tensile strength as skin that has never been injured.

False.

When obtaining a wound culture, where should the sample be collected from?

Viable tissue in a zig-zag pattern after cleansing.

What is a key principle for caring for a dry wound?

Use dressings that promote moisture retention.

What is the most important nursing intervention to prevent moisture-associated dermatitis (MASD) in a patient with fecal incontinence?

Gentle cleaning of the area and keeping it dry from urine and stool.

True or False: The Braden Scale is used to assess the characteristics of an existing pressure injury.

False.

What does separation of the wound edges with visible subcutaneous tissue indicate?

A full-thickness wound with potential dehiscence.