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WorksheetsWound Care Test Questions
Total questions: 54
Worksheet time: 55mins
The three layers of the skin include all except the
epidermis
dermis
subcutaneous
subdermis
List three physiological changes of the skin related to aging:
Pressure ulcers are usually located over bony prominences and caused by unrelieved pressure resulting in damage of underlying tissue.
True
False
Initial assessment of a pressure ulcer must include:
the location, the size (length x width x depth), the stage
sinus tracts, undermining, tunneling, exudate
necrotic tissue, presence of absence of granulation tissue, epithelialization
all of the above
List three risk factors for developing a pressure ulcer:
Low-air-loss and air-fluidized beds are only indicated for residents with stage III or stage IV pressure ulcers.
True
False
A pressure ulcer that is superficial and presents as a blister with partial thickness skin loss involving epidermis and dermis is graded as a
stage I
stage II
stage III
stage IV
A stage I pressure ulcer will present with
warmth and edema,
induration or hardness,
nonblanchable erythema
discoloration of the skin
all of the above
While sitting in a wheelchair, the resident should be encouraged to change position or shift his/her weight at least every
every 30 minutes
every 1 hour
every 45 minutes
every 2 hours
When floating heels off of the mattress, the heels should be raised
enough for your hand to fit between the bed and the heels
2 inches off of the bed
just enough for a piece of paper to pass between the bed and the heels
at least one inch off the bed
Donut-type devices are the recommended positioning device for residents at risk for development of pressure ulcers.
True
False
This term is used if a support device is found to be inadequate and is determined by placing an outreached hand under the overlay below the pressure ulcer or below the part of the body at risk for a pressure ulcer.
bottoming out
pressure reduction
shear reduction
positioning management
List three preventative measures to take when a resident is at risk for developing pressure ulcers:
Define sterile technique as related to pressure ulcer care:
Define clean technique as related to pressure ulcer care :
Removal of devitalized tissue in pressure ulcers when appropriate for the resident’s condition and consistent with resident goals is
irrigation
sterile technique
debridement
exudates
Wounds need to be cleaned initially and at each dressing change.
True
False
The cardinal rule when determining a dressing change for a pressure ulcer is
keep the ulcer tissue dry and the surrounding intact skin moist
keep the ulcer tissue moist and the surrounding intact skin dry
keep the ulcer tissue and surrounding intact skin moist
keep the ulcer tissue and surrounding intact skin dry
A 2 week trial of topical antibiotic ointment should be considered
for pressure ulcers that continue to produce exudates after 2-4 weeks of optimal resident care
for clean pressure ulcers that are not healing
both a. and b.
none of the above
List three clinical signs of infection of a pressure ulcer:
To prevent cross contamination of wound supplies, individual residents should have their own dressing supplies.
True
False
Pressure ulcer care must be performed with sterile gloves.
True
False
List three physiologic changes associated with aging that can impact nutritional status:
To prevent pressure ulcers, which of the following interventions are appropriate?
Frequency of skin assessments may need to be increased if the residents status deteriorates.
Keep the head of the bed above a 30 degree angle at all times to reduce pressure and shearing force on the sacral area.
When positioning or lifting up the resident in bed, health care providers should not drag skin across linens to prevent skin injury cause by friction and shearing
Both a. and b.
Both a. and c.
What is the most severe type of pressure ulcer?
stage III
stage I
stage IV
stage II
Identify three nutritional interventions that may be taken when someone has a pressure ulcer:
Water is the largest component of the body.
True
False
List three functions of water in the body.
This nutrient repairs the body from wear and tear, builds new tissue and contributes to numerous essential body functions.
protein
carbohydrate
fat
sugar
A pressure ulcer that presents as a deep crater with or without undermining adjacent tissue is
stage I
stage II
stage III
stage IV
Systemic antibiotic therapy should be initiated for residents with all except:
bacteremia
sepsis
osteomyelitis
colonization
The intact skin surrounding a pressure ulcer is called
wound bed
periulcer
subdermis
abscess
Which type(s) of dressing requires the least amount(s) of time
wet to dry dressing
hydrocolloid dressing
film dressing
both b. and c.
Dehydration and malnutrition are risk factors for developing pressure ulcers.
True
False
The following labs are indicators that place a resident at risk of development for pressure ulcers:
serum albumin level less than 3.5g/dL
weight loss greater than 10 percent in the last month
hemoglobin level less than 12g/dL
all of the above
Physiological changes associated with aging that affect nutritional intake do not include
changes in taste and smell
decrease in the ability to concentrate urine and decreased thirst
decrease in GI motility
decrease in hearing and cognition
decrease in lean body mass
Adults can live only about 10 days without water as opposed to several weeks without food.
True
False
Water
helps maintain body temperature
serves as the building material for growth and repair of the body
plays an important role in cell metabolism
all of the above
This vitamin helps the formation of collagen, maintains the intracellular cement substance and helps with iron absorption
Thiamine
Vitamin A
Vitamin C
Zinc
Performing non sterile wound care requires less time than sterile wound care.
True
False
The wound healing process does not include:
inflammatory phase
proliferation phase
infection phase
maturation phase
With aging, the skin (epidermis)
does not change
becomes thicker and dryer
becomes thinner and dryer
When documenting on a pressure ulcer, daily assessment should include all but
vital signs
location of pressure ulcer
odor present
drainage, if purulent
Daily documentation should also include
communication to physicians
communication to responsible party
complaints of pain
all of the above
Weekly assessments and documentation of pressure ulcers, should include
All listed below
Stage of ulcer, including size (width, length, depth)
Location of ulcer
Odor and drainage, including color and amount
Description of tissue
Downsizing of pressure ulcers is recorded when documenting the healing process of a pressure ulcer.
True
False
The following note would not be appropriate for supportive documentation of a pressure ulcer:
No improvement seen in sacral pressure ulcer
Pressure ulcer worse.
Physician notified of progress in wound and new order received.
Open area has increased from 3 cm in diameter x 1 cm deep as of last week to 5 cm diameter x 2 cm deep.
The following note would be supportive documentation for dressing changes:
Sacral ulcer rinsed and covered with clean dressing.
Sacral pressure ulcer rinsed with normal saline and covered with 6 4x4s
Sacral ulcer cleansed
Sacral ulcer treatment done as ordered
List 4 signs and symptoms of dehydration.
Zinc supplements do not increase rates of wound healing when zinc levels are normal.
True
False
A 30% loss of LBM (lean body mass) will significantly decrease and possibly stop all wound healing until LBM is restored.
True
False
When a pressure ulcer is draining purulent material, consider it infected.
True
False
What type of product protects the skin better and longer from incontinence?
Powders
Moisturizers
Moisture Barriers
Lotions
Cleansers
Using the face of a clock as a reference point Length is measured from __ o’clock to __ o’clock
