Skin Integrity Practice Questions

Which finding(s) are characteristic of a stage 3 pressure injury? Select all that apply.

• It has full-thickness skin loss.

• The subcutaneous fat may be visible.

• The wound may present as an open, serum-filled blister.

• There may be a reddish-pink wound bed without slough.

• Neither the bone, tendon, nor muscle is exposed.

Answer explanation

A stage 3 pressure injury has a full-thickness skin loss involving the epidermis and dermis. Because of this, the subcutaneous fat may be visible. However, the wound is not deep enough to expose the bone, tendon, or the muscle. A wound with an open, serum-filled blister or one having a reddish-pink wound bed without slough is a stage 2 pressure injury.

A patient with darkly pigmented skin is on strict bedrest. While examining the patient, which characteristic(s) will determine that the patient has developed a pressure injury? Select all that apply.

• The skin color remains unchanged on application of pressure.

• The localized area of the skin appears purple.

• There is blanching of the skin.

• The area of the skin with a pressure injury has erythema.

• Temperature changes in the skin can be palpated.

Answer explanation

For patients with darkly pigmented skin, the localized area of the skin appears purple or blue. Blanching of the skin does not occur.  The skin may feel cool or warm.

A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long-term care facility using for risk assessment of pressure injury development?

• Gaskin's Nursing Assessment of Skin Color (GNASC) tool

• Braden Scale

• Bates-Jensen Wound Assessment Tool (BWAT)

• Wound, Ostomy, and Continence Nurses Society (WOCN) scale

Answer explanation

The Braden Scale is a widely used tool for risk assessment of pressure injury development and is composed of six subscales that are moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. The GNASC tool is used to assess stage 1 pressure injuries in patients with dark skin tone. The BWAT is used to assess the wound status. WOCN does not provide any measurement or assessment tools.

The nurse works in a long-term care unit. Which patient(s) would be at high risk of developing pressure injuries? Select all that apply.

• The patient with a spinal cord injury

• A comatose patient

• The patient with urinary incontinence

• A patient who is immobile with excessive wound drainage

• A postoperative patient after a laparoscopic cholecystectomy

Answer explanation

The patient with a spinal injury is immobile and is dependent on the health care team for changes in position. This patient is at risk of developing pressure injuries because of remaining in the same position for a long time. A comatose patient has impaired perception of pain and pressure, is immobile, and is at increased risk of developing pressure injuries. The patient with urinary incontinence is at risk of impaired skin integrity as a result of the urine irritating the skin. The patient may develop pressure injuries because of constant exposure to moisture. The patient who is immobile and has excessive wound drainage may be at an increased risk as a result of the skin being exposed to moisture. The patient who underwent laparoscopic cholecystectomy is active and not immobile. The patient is not at risk of developing pressure injuries.

Which stage of pressure injury is noted to have intact skin and may include changes in skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

• 1

• 2

• 3

• 4

Answer explanation

A stage 1 pressure injury does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or may feel soft if the blood flow is compromised. The patient may report pain in the area. Stages 2, 3, and 4 all have breaks in the skin at different degrees of depth.

A patient is admitted with a stage 2 pressure injury. Which characteristic of a pressure injury is the nurse likely to find during a wound assessment?

• It has a reddish-pink wound bed without slough.

• The subcutaneous fat is visible.

• It may include undermining and tunneling.

• The wound extends to muscles and bones.

Answer explanation

A stage 2 pressure injury has a partial thickness loss of dermis and is shallow. It has a reddish-pink wound bed without slough. The subcutaneous fat is visible in a stage 3 pressure injury because of a full-thickness tissue loss. Stage 3 and stage 4 wounds involve undermining and tunneling. A stage 3 wound extends to the muscles and bones, because there is a full-thickness tissue loss.

The edges of a patient's surgical incision are approximated, and no drainage is noted. Which type of healing does this signify?

• Granulation

• Primary intention

• Tertiary intention

• Secondary intention

Answer explanation

Primary intention is the use of sutures or other wound closures to approximate the edges of an incision or a clean laceration. This reduces the risk of infection. Granulation tissue is formed to fill the gap between the edges of a wound and eventually fills in the surface of the wound. Healing by tertiary intention occurs with injuries and wounds and results in scar formation. Secondary intention wound healing occurs more slowly than primary intention.

After surgery, the patient with a closed abdominal wound reports a sudden 'pop' after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention would the nurse do first?

• Allow the area to be exposed to air until all drainage has stopped.

• Place several cold packs over the area, protecting the skin around the wound.

• Cover the area with sterile, saline-soaked gauze and immediately notify the surgical team; this is likely to indicate a wound evisceration.

• Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

Answer explanation

If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile gauze moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist. Allowing the area to be exposed to air until all drainage has stopped invites infection and could cause the exposed bowel to become necrotic. Cold packs should not be used, as they could freeze the sensitive exposed bowel portions and decrease blood flow to them, which might result in necrosis. This is not a minor opening, and the patient should be prepped for immediate surgery. A binder should not be applied, as it may damage the exposed bowel.

The nurse is teaching a group of nursing students about the role of nutrients in wound healing. Which statement(s) are correct? Select all that apply.

• Fats are the most essential elements for tissue repair and growth.

• Protein needs are increased and are essential for tissue repair and growth.

• Trace elements are required for epithelialization and collagen fiber linking.

• Calories provide the energy source needed for cellular activities involved in wound healing.

• A balanced intake of protein, fat, carbohydrates, vitamins, and minerals is critical to support wound healing.

Answer explanation

A balanced nutritional intake promotes wound healing. Protein needs especially are increased and are essential for tissue repair and growth. Collagen is a protein and is a critical component in wound healing. Calorie requirements are high to provide the energy for cellular activity in wound healing. If calories are deficient, the body starts breaking down fats for energy, which may be detrimental to wound healing. A balanced intake of various nutrients such as protein, fat, carbohydrates, vitamins, and minerals is important for wound healing. Trace elements such as zinc and copper are required for epithelialization and collagen fiber linking. Fats have no role in wound healing.

While caring for a patient in the postsurgical unit, the nurse palpates the area around the surgical wound and asks the patient if there is tenderness. This nursing action is taken to assess the risk of which condition?

• Abrasion

• Hematoma

• Evisceration

• Periwound edema

Answer explanation

The nurse may assess the patient for periwound edema and pain by palpating the affected area for tenderness. An abrasion is a small superficial wound with little damage to the capillaries. Swelling, bluish discoloration, sensation, and warmth are signs of a hematoma. Evisceration is an emergency condition in which visceral organs protrude out through the wound opening. Abrasion, hematoma, and evisceration can be observed with visual inspection; palpation is not necessary.