Skin Integrity Past Paper PDF

Multiple Choice Questions: 1. Which layer of the skin is primarily responsible for resurfacing a wound and restoring the barrier against invading organisms? o A) Dermis o B) Epidermis o C) Subcutaneous tissue o D) Hypodermis Answer: B) Epidermi...

Multiple Choice Questions: 1. Which layer of the skin is primarily responsible for resurfacing a wound and restoring the barrier against invading organisms? o A) Dermis o B) Epidermis o C) Subcutaneous tissue o D) Hypodermis Answer: B) Epidermis Rationale: The epidermis resurfaces wounds and restores the skin’s protective barrier. 2. Which phase of wound healing involves clot formation to stop bleeding? o A) Maturation o B) Inflammatory o C) Hemostasis o D) Proliferative Answer: C) Hemostasis Rationale: Hemostasis involves vasoconstriction and clot formation to stop bleeding and initiate wound healing. 3. What is the primary characteristic of a stage II pressure injury? o A) Non-blanchable erythema o B) Full-thickness skin loss o C) Partial-thickness skin loss o D) Deep tissue injury Answer: C) Partial-thickness skin loss Rationale: Stage II pressure injuries involve partial-thickness skin loss, often presenting as a shallow open ulcer. 4. What factor contributes most to the development of a pressure injury? o A) Malnutrition o B) Shear and friction o C) Urinary incontinence o D) All of the above Answer: D) All of the above Rationale: Pressure injuries are caused by a combination of factors like malnutrition, shear, friction, and incontinence. 5. Which dressing type promotes moist wound healing and protects the wound? o A) Hydrocolloid dressing o B) Gauze o C) Transparent film o D) Foam dressing Answer: A) Hydrocolloid dressing Rationale: Hydrocolloid dressings maintain a moist environment conducive to wound healing. 6. Which of the following is NOT a risk factor for pressure injury development?  o A) Impaired mobility o B) Malnutrition o C) Hypertension o D) Altered level of consciousness Answer: C) Hypertension Rationale: Hypertension is not directly related to pressure injury development compared to impaired mobility or malnutrition. 7. In which wound healing phase do new blood vessels and granulation tissue develop? o A) Hemostasis o B) Inflammatory o C) Proliferative o D) Maturation Answer: C) Proliferative Rationale: During the proliferative phase, new blood vessels form, and granulation tissue fills the wound. 8. Which of the following is an early sign of wound infection? o A) Decreased wound drainage o B) Erythema and warmth o C) Wound dehiscence o D) Minimal pain Answer: B) Erythema and warmth Rationale: Infection is often indicated by erythema, warmth, and increased drainage. 9. What is the first intervention for evisceration? o A) Apply a dry sterile dressing o B) Call the surgeon immediately o C) Cover the wound with sterile gauze soaked in saline o D) Reinsert the organs manually Answer: C) Cover the wound with sterile gauze soaked in saline Rationale: Evisceration is an emergency. The wound should be covered with sterile saline gauze to prevent drying and infection. 10. Which tool is commonly used to assess a patient's risk for pressure injury? o A) Glasgow Coma Scale o B) Braden Scale o C) APGAR Score o D) Mini-Mental State Examination Answer: B) Braden Scale Rationale: The Braden Scale assesses a patient’s risk for developing pressure injuries based on factors like mobility and nutrition. Application Questions: 11. A 78-year-old bedridden patient develops a pressure injury on their sacral area. What nursing intervention is most appropriate to prevent further injury?  o A) Keep the patient flat in bed o B) Reposition the patient every 2 hours o C) Apply hot compresses to the area o D) Increase the patient’s calorie intake by 500 calories Answer: B) Reposition the patient every 2 hours Rationale: Frequent repositioning helps reduce pressure on bony prominences and prevents further injury. 12. Your patient has a surgical wound with serosanguineous drainage. What is the nurse’s priority action? o A) Increase the patient's fluid intake o B) Continue to monitor the drainage o C) Apply an antibiotic ointment o D) Notify the physician immediately Answer: B) Continue to monitor the drainage Rationale: Serosanguineous drainage is normal in healing wounds. Monitoring ensures no complications develop. 13. A patient with diabetes presents with a non-healing foot ulcer. What factor is most likely impairing wound healing? o A) Infection o B) Increased circulation o C) Proper nutrition o D) Low blood sugar Answer: A) Infection Rationale: Diabetes impairs wound healing, often leading to infection, which can delay the healing process. 14. Your patient is receiving wound care for a stage III pressure injury. Which intervention will promote healing? o A) Apply dry gauze to absorb excess drainage o B) Apply a moist wound dressing o C) Clean with hydrogen peroxide daily o D) Reposition the patient once a shift Answer: B) Apply a moist wound dressing Rationale: Maintaining a moist environment with appropriate dressings facilitates wound healing. 15. A patient has a deep tissue injury with eschar present. What is the nurse’s next step in wound care? o A) Debride the wound to remove nonviable tissue o B) Apply a dry dressing over the eschar o C) Allow the eschar to slough off naturally o D) Leave the wound open to air Answer: A) Debride the wound to remove nonviable tissue Rationale: Removing nonviable tissue through debridement is essential to promote healing in deep tissue injuries. Which term describes the separation of layers in a healing surgical wound?  A) Evisceration B) Dehiscence C) Fistula D) Hemorrhage Answer: B) Dehiscence Rationale: Dehiscence refers to the partial or total separation of wound layers during the healing process, commonly occurring before collagen formation. Which wound complication involves the protrusion of internal organs through a wound opening? A) Fistula B) Dehiscence C) Evisceration D) Abscess Answer: C) Evisceration Rationale: Evisceration occurs when internal organs protrude through an open wound, requiring immediate surgical intervention. Which of the following is NOT a stage of wound healing? A) Hemostasis B) Granulation C) Necrosis D) Maturation Answer: C) Necrosis Rationale: Necrosis refers to dead tissue, not a phase of wound healing. The stages of wound healing are hemostasis, inflammatory, proliferative (granulation), and maturation. A patient has a stage IV pressure injury. Which of the following best describes this stage? A) Non-blanchable erythema of intact skin B) Partial-thickness skin loss with exposed dermis C) Full-thickness skin and tissue loss with exposed bone, muscle, or tendon D) Deep tissue injury without skin breakage Answer: C) Full-thickness skin and tissue loss with exposed bone, muscle, or tendon Rationale: Stage IV pressure injuries involve full-thickness tissue loss with visible bone, muscle, or tendon. Which type of wound healing is characterized by the edges of the wound being approximated, such as in surgical incisions? A) Secondary intention B) Tertiary intention C) Primary intention  D) Delayed intention Answer: C) Primary intention Rationale: Primary intention occurs when wound edges are brought together, as in surgical incisions, allowing for quicker healing with minimal scarring. What is the purpose of applying a hydrocolloid dressing to a wound? A) To absorb excessive wound drainage B) To prevent infection C) To maintain a moist environment for wound healing D) To dry out the wound Answer: C) To maintain a moist environment for wound healing Rationale: Hydrocolloid dressings promote healing by maintaining a moist environment that supports cell migration and tissue growth. Which phase of wound healing involves the formation of granulation tissue and the appearance of new blood vessels? A) Inflammatory phase B) Proliferative phase C) Maturation phase D) Hemostasis phase Answer: B) Proliferative phase Rationale: During the proliferative phase, granulation tissue forms, and new blood vessels appear to support tissue repair. Which risk factor is most likely to contribute to the development of pressure injuries in an immobile patient? A) Impaired sensory perception B) Increased mobility C) High-protein diet D) Good nutritional status Answer: A) Impaired sensory perception Rationale: Patients with impaired sensory perception are unable to feel pressure or discomfort, making them more susceptible to pressure injuries. Which of the following is a common cause of shear-related pressure injuries? A) Sliding down in bed with the head of the bed elevated B) Immobility in a sitting position C) Inadequate nutrition D) Chronic illness Answer: A) Sliding down in bed with the head of the bed elevated Rationale: Shear injuries occur when the skin remains in place while underlying tissues move, commonly caused by sliding down in bed with the head elevated.  Which of the following describes the inflammatory response in wound healing? A) Constriction of blood vessels and clot formation B) Migration of white blood cells to the wound site C) Formation of new collagen D) Resurfacing of the wound with new epithelial cells Answer: B) Migration of white blood cells to the wound site Rationale: During the inflammatory phase, white blood cells migrate to the wound site to fight infection and begin the healing process. A patient presents with a stage III pressure injury on the heel, with visible slough and moderate drainage. What is the most appropriate first intervention? A) Apply a hydrogel dressing B) Debride the wound to remove nonviable tissue C) Apply a dry gauze dressing D) Elevate the heel without applying any dressing Answer: B) Debride the wound to remove nonviable tissue Rationale: In stage III pressure injuries with slough, debridement is necessary to remove necrotic tissue and promote healing. A nurse is caring for a patient with a sacral pressure injury who is incontinent of urine. What nursing intervention will help protect the skin from moisture-associated damage? A) Cleanse the skin with soap and water after each episode of incontinence B) Apply an incontinence barrier cream to protect the skin C) Reposition the patient every 4 hours D) Leave the skin exposed to air Answer: B) Apply an incontinence barrier cream to protect the skin Rationale: Barrier creams protect the skin from moisture and reduce the risk of maceration and further injury. A patient recovering from surgery has a surgical wound with a Jackson-Pratt (JP) drain in place. What is the nurse's priority action during wound care? A) Measure the amount of drainage from the JP drain B) Irrigate the JP drain site daily with normal saline C) Remove the JP drain once drainage decreases D) Leave the drain untouched to avoid contamination Answer: A) Measure the amount of drainage from the JP drain Rationale: Measuring drainage is important to monitor wound healing and detect complications such as infection or excessive bleeding. A patient with a large abdominal wound is at risk for dehiscence. Which action should the nurse take to prevent this complication?  A) Encourage ambulation every 2 hours B) Apply a binder to support the wound C) Keep the patient’s head elevated to 45 degrees D) Clean the wound with hydrogen peroxide Answer: B) Apply a binder to support the wound Rationale: A binder helps support the wound and reduce strain, which lowers the risk of dehiscence, especially in abdominal wounds. A nurse is educating a patient and their family about home wound care for a stage II pressure injury. What instruction should be prioritized in the teaching plan? A) Clean the wound with an antiseptic solution daily B) Change the dressing at least once a week C) Apply a hydrocolloid dressing and monitor for signs of infection D) Expose the wound to air whenever possible Answer: C) Apply a hydrocolloid dressing and monitor for signs of infection Rationale: Using a hydrocolloid dressing supports moist wound healing, and monitoring for signs of infection is critical in preventing complications during home care. A nurse is preparing to change a dressing on a patient’s surgical wound. What is the correct sequence of steps to ensure proper aseptic technique? A) Remove the old dressing, apply new dressing, clean the wound B) Wash hands, remove the old dressing, clean the wound, apply the new dressing C) Apply sterile gloves, clean the wound, remove the old dressing, apply the new dressing D) Remove the old dressing, clean the wound, then apply sterile gloves and the new dressing Answer: B) Wash hands, remove the old dressing, clean the wound, apply the new dressing Rationale: Proper aseptic technique involves washing hands first, followed by removing the old dressing, cleaning the wound, and applying a new sterile dressing. A nurse is assessing a patient with a stage I pressure injury on their sacrum. What would be the appropriate nursing intervention to prevent the progression of the injury? A) Apply a foam dressing B) Reposition the patient at least every 2 hours C) Apply a moist-to-dry dressing D) Apply a hydrocolloid dressing Answer: B) Reposition the patient at least every 2 hours Rationale: Repositioning the patient frequently prevents prolonged pressure on bony prominences, which can worsen a stage I pressure injury.  A patient with a leg wound is prescribed wet-to-dry dressings. What is the primary purpose of this treatment? A) To prevent infection by keeping the wound dry B) To debride the wound by removing dead tissue when the dressing is removed C) To provide a moist environment to promote epithelialization D) To maintain constant pressure on the wound Answer: B) To debride the wound by removing dead tissue when the dressing is removed Rationale: Wet-to-dry dressings are designed to mechanically debride the wound by adhering to dead tissue, which is removed when the dressing is taken off. A nurse is caring for a patient with impaired mobility and high risk for pressure injuries. Which of the following would best prevent the development of pressure injuries? A) Elevate the head of the bed to 45 degrees B) Use a donut cushion under the patient’s sacrum C) Place the patient in a 30-degree lateral position D) Reposition the patient every 4 hours Answer: C) Place the patient in a 30-degree lateral position Rationale: The 30-degree lateral position reduces pressure on bony prominences such as the sacrum and heels, minimizing the risk of pressure injuries. A nurse needs to irrigate a patient’s wound. Which of the following describes the correct technique for wound irrigation? A) Irrigate from the most contaminated area to the least contaminated area B) Use cold water to prevent damaging tissue C) Irrigate from the least contaminated area to the most contaminated area D) Irrigate using a continuous flow of high-pressure water Answer: C) Irrigate from the least contaminated area to the most contaminated area Rationale: Irrigation should be done from the least contaminated to the most contaminated area to avoid introducing bacteria into the wound. A nurse is educating a family member on how to assist a patient with dressing changes at home. Which competency should be demonstrated to ensure safe and effective care? A) Applying the dressing before cleaning the wound B) Correct hand hygiene before and after dressing changes C) Removing dressings using clean gloves, without using sterile technique D) Cleaning the wound from the surrounding skin toward the center Answer: B) Correct hand hygiene before and after dressing changes  Rationale: Proper hand hygiene is critical to preventing infections during wound care. It must be demonstrated and maintained throughout the procedure. A patient with diabetes has a non-healing wound on their foot. What is the most appropriate nursing intervention to promote wound healing? A) Apply a dry sterile dressing and change it daily B) Ensure that the patient maintains a high-protein diet C) Apply hydrogen peroxide to the wound D) Elevate the foot to reduce blood flow Answer: B) Ensure that the patient maintains a high-protein diet Rationale: Adequate nutrition, particularly protein, is essential for wound healing, especially in patients with diabetes who have delayed healing. A patient with a deep tissue pressure injury is scheduled for a wound dressing change. Which action by the nurse demonstrates competency in wound care management? A) Apply a transparent dressing directly over the necrotic tissue B) Use sterile technique to prevent infection during the dressing change C) Pack the wound tightly with gauze to absorb excess drainage D) Soak the dressing in hydrogen peroxide before applying it Answer: B) Use sterile technique to prevent infection during the dressing change Rationale: Using sterile technique is crucial to preventing infection in patients with deep tissue injuries. A nurse is reviewing the nutritional needs of a patient with multiple pressure injuries. Which dietary component is most important for wound healing? A) Carbohydrates B) Fats C) Protein D) Sodium Answer: C) Protein Rationale: Protein is the most important nutrient for wound healing, as it helps build and repair body tissues. A patient with a wound is at risk for delayed healing due to poor circulation. Which intervention should the nurse prioritize? A) Keep the patient’s legs elevated at all times B) Encourage the patient to ambulate frequently if possible C) Apply cold compresses to reduce inflammation D) Wrap the wound tightly with a compression bandage Answer: B) Encourage the patient to ambulate frequently if possible Rationale: Ambulation promotes circulation and tissue oxygenation, which are essential for wound healing. Additional Competency-Based Questions: 41. A nurse observes a red, non-blanchable area on a patient's sacrum. What is the first action the nurse should take? o A) Apply a warm compress o B) Document the finding and continue monitoring o C) Reposition the patient off the affected area o D) Apply an antibiotic ointment Answer: C) Reposition the patient off the affected area Rationale: A red, non-blanchable area indicates a stage I pressure injury. Repositioning helps to relieve pressure and prevent further damage. 42. A patient with a chronic venous ulcer requires wound debridement. Which type of debridement is most appropriate for a nurse to perform independently? o A) Sharp debridement o B) Autolytic debridement o C) Surgical debridement o D) Enzymatic debridement Answer: B) Autolytic debridement Rationale: Autolytic debridement uses the body’s own enzymes and moisture to break down necrotic tissue and can be done with dressings such as hydrocolloid or transparent film. 43. A patient asks the nurse why it is important to keep their wound moist. What is the best response? o A) "Moist wounds heal faster and promote cell migration." o B) "Dry wounds are more prone to infection." o C) "Moist wounds prevent scarring." o D) "Moist wounds allow dressings to adhere better." Answer: A) "Moist wounds heal faster and promote cell migration." Rationale: Keeping a wound moist accelerates healing by facilitating cell migration and preventing the wound from drying out. 44. A nurse is preparing to apply negative pressure wound therapy (NPWT). Which competency is most critical before starting the procedure? o A) Understanding the mechanism of the NPWT device o B) Ensuring a moist wound bed is present o C) Checking for contraindications such as exposed blood vessels o D) Applying a thick layer of gauze to the wound Answer: C) Checking for contraindications such as exposed blood vessels Rationale: It is essential to assess for contraindications (e.g., exposed blood vessels) to avoid complications during NPWT. 45. A nurse is caring for a patient with a wound that has moderate serous drainage. What is the best dressing option for managing this drainage? o A) Transparent film o B) Gauze o C) Foam dressing o D) Hydrogel Answer: C) Foam dressing  Rationale: Foam dressings are highly absorbent and are ideal for managing moderate to heavy drainage while maintaining a moist wound environment. 46. A nurse is assessing a patient’s wound and notes thick, yellow drainage with a foul odor. What should the nurse do next? o A) Change the dressing and continue to monitor o B) Document the findings as normal healing o C) Notify the healthcare provider immediately o D) Apply a hydrocolloid dressing to absorb the drainage Answer: C) Notify the healthcare provider immediately Rationale: Thick, yellow drainage with a foul odor may indicate infection, and the healthcare provider should be notified for further evaluation and treatment. 47. A patient with diabetes is at high risk for foot ulcers. What is the most important intervention for the nurse to teach the patient to prevent foot wounds? o A) Wear tight-fitting shoes to protect the feet o B) Inspect feet daily for cuts or sores o C) Apply alcohol-based lotion to the feet o D) Soak the feet daily in warm water Answer: B) Inspect feet daily for cuts or sores Rationale: Daily foot inspection helps patients detect any cuts, sores, or signs of infection early, preventing the development of serious ulcers. 48. The nurse is teaching a family member how to change a dressing for a patient with a stage II pressure injury. Which instruction is most critical to ensure proper wound care? o A) Apply a thick layer of antiseptic ointment o B) Wash hands thoroughly before and after the procedure o C) Use sterile gloves to handle the new dressing o D) Change the dressing only when it becomes saturated Answer: B) Wash hands thoroughly before and after the procedure Rationale: Proper hand hygiene is critical to prevent infection during the dressing change process. 49. A nurse is preparing to apply a sterile dressing to a patient’s wound. Which action demonstrates the correct technique for maintaining a sterile field? o A) Touching the edges of the sterile dressing with clean gloves o B) Keeping all sterile supplies above waist level o C) Allowing the sterile field to come into brief contact with the patient's skin o D) Discarding any unused sterile supplies after the procedure Answer: B) Keeping all sterile supplies above waist level Rationale: Maintaining the sterile field above waist level helps prevent contamination and ensures sterility is preserved throughout the procedure. 50. A nurse is caring for a patient with a deep pressure injury that requires packing. What is the most important consideration when packing the wound? o A) Packing the wound tightly to fill the entire space o B) Using a sterile, moist dressing material to fill the wound o C) Using dry gauze to promote absorption of exudate o D) Changing the packing only when the dressing is completely saturated Answer: B) Using a sterile, moist dressing material to fill the wound Rationale: The wound should be packed loosely with sterile, moist dressing to promote healing and avoid causing damage to the surrounding tissues.