Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank
Chapter 48: Skin Integrity and Wound Care
MULTIPLE CHOICE
1. The nurse determines that the clients wound may be infected. To perform an aerobic
wound culture, the nurse should:
1. Collect the superficial drainage
2. Collect the culture before cleansing the wound
3. Obtain a culturette tube and use sterile technique
4. Use the same technique as for collecting an anaerobic culture
ANS: 3
The nurse uses different methods of specimen collection for aerobic or anaerobic
organisms.
To collect an aerobic wound culture, the nurse uses a sterile swab from a culturette tube
and sterile technique. The nurse never collects a wound culture sample from old or
superficial drainage. Resident colonies of bacteria from the skin grow in superficial
drainage and may not be the true causative organisms of a wound infection. The nurse
should clean a wound first with normal saline to remove skin flora before obtaining the
culture.
DIF: A
REF: 1299
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
2. Pressure ulcers form primarily as a result of:
1. Nitrogen buildup in the underlying tissues
2. Prolonged illness or disease
3. Tissue ischemia
4. Poor nutrition
ANS: 3
Pressure is the major cause of pressure ulcer formation. Prolonged, intense pressure
affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue
ischemia and ultimately tissue death. Prolonged illness or disease and poor nutrition may
place a client at risk for pressure ulcer development.
DIF: A
REF: 1280
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
3. The nurse notes a clients skin is reddened with a small abrasion and serous fluid present.
The nurse should classify this stage of ulcer formation as:
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Test Bank
1.
2.
3.
4.

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Stage I
Stage II
Stage III
Stage IV

ANS: 2
This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is
defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is
superficial and presents clinically as an abrasion, blister, or shallow crater. A stage I
pressure ulcer is an observable pressure-related alteration of intact skin whose indicators
may include changes in one or more of the following: skin temperature, tissue
consistency, and/or sensation. A stage III pressure ulcer has full-thickness skin loss
involving damage or necrosis of subcutaneous tissue that may extend down to, but not
through, underlying fascia. A stage IV pressure ulcer has full-thickness skin loss with
extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting
structures.
DIF: A
REF: 1282
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
4. The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat
immobile because of arthritic discomfort. Which of the following is the best intervention
for the clients skin integrity?
1. Having the client sit up in a chair for 4-hour intervals
2. Keeping the head of the bed in a high-Fowlers position to increase circulation
3. Keeping a written schedule of turning and positioning
4. Encouraging the client to perform pelvic muscle training exercises several times a
day
ANS: 3
The frequency of repositioning should be individualized for the client; however, clients
should be repositioned at least every 2 hours. The Agency for Healthcare Research and
Policy (AHRQ) guidelines recommend that a written turning and positioning schedule be
used. Clients able to sit in a chair should be limited to sitting for 2 hours or less.
Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure
ulcer development from shearing forces. Pelvic muscle training may help prevent
incontinence, but it is not the best intervention for maintaining the clients skin integrity.
DIF: A
REF: 1304
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
5. Upon changing the clients dressing, the nurse notes that the wound appears to be
granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is:

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Test Bank
1.
2.
3.
4.

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Sterile saline
Hydrogen peroxide
Povidone-iodine (Betadine)
Sodium hypochlorite (Dakins solution)

ANS: 1
Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic, such
as normal saline. Normal saline will not damage or kill cells, such as fibroblasts and
healing tissue. Hydrogen peroxide, povidone-iodine (Betadine), and sodium hypochlorite
(Dakins solution) are cytotoxic and therefore should not be used to clean a wound that is
granulating.
DIF: A
REF: 1307
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
6. A client requires wound debridement. The nurse is aware that which one of the following
statements is correct regarding this procedure?
1. It allows the healthy tissue to regenerate.
2. When performed by autolytic means, the wound is irrigated.
3. Mechanical methods involve direct surgical removal of the eschar layer of the
wound.
4. Enzymatic debridement may be implemented independently by the nurse whenever
it is required.
ANS: 2
Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable
visualization of the wound bed, and to provide a clean base necessary for healthy tissue to
regenerate. Autolytic debridement uses synthetic dressings over a wound to allow the
eschar to be self-digested by the action of enzymes that are present in wound fluids. The
wound is not irrigated. Mechanical methods include wet-to-dry dressings, wound
irrigation, and whirlpool treatments. Surgical debridement involves direct surgical
removal of the eschar layer of the wound. Enzymatic debridement requires a health care
providers order.
DIF: A
REF: 1307
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
7. The nurse prepares to irrigate the clients wound. The primary reason for this procedure is
to:
1. Decrease scar formation
2. Remove debris from the wound
3. Improve circulation from the wound
4. Decrease irritation from wound drainage

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ANS: 2
The gentle washing action of the irrigation cleanses a wound of exudate and debris. The
primary purpose of wound irrigation is not to improve circulation, decrease scar
formation, or decrease irritation from wound drainage, but to remove debris from the
wound.
DIF: A
REF: 1307
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
8. When turning a client, the nurse notices a reddened area on the coccyx. What skin care
interventions should the nurse use on this area?
1. Clean the area with mild soap, dry, and add a protective moisturizer.
2. Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the
area.
3. Soak the area in normal saline solution.
4. Wash the area with an astringent and paint it with povidone-iodine (Betadine).
ANS: 1
The skin should be cleansed and completely dried and a protective moisturizer applied to
keep the epidermis well lubricated. Hydrogen peroxide is cytotoxic and should not be
used. A heat lamp is not necessary and would increase the clients risk for an accidental
burn. The area should not be soaked because this may lead to maceration of the skin. The
area should not be cleansed with an astringent and painted with povidone-iodine. An
astringent may cause excessive drying of the tissue, and povidone-iodine is cytotoxic.
DIF: A
REF: 1304
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
9. A client with a large abdominal wound requires a dressing change every 4 hours. The
client will be discharged to the home setting, where the dressing care will be continued.
Which of the following is true concerning this clients wound healing process?
1. An antiseptic agent is best followed with a rinse of sterile saline solution.
2. A heat lamp should be used every 2 hours to rid the wound area of contaminants.
3. Sterile technique should be emphasized to the client and family.
4. A dressing covering will allow the wound area to remain moist.
ANS: 4

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A dressing should support a moist wound environment if the wound is healing by

secondary intention, such as with a large abdominal wound. A moist wound base
facilitates the movement of epithelialization, thus allowing the wound to resurface as
quickly as possible. Only mild soap may be used or saline. Antiseptics may be damaging
to granulation tissue. A heat lamp should not be used because it will dry out the wound
and impair the movement of epithelialization. Clean dressings may be used in the home
setting.
DIF: A
REF: 1312
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
10. Upon inspection of the clients wound, the nurse notes that it appears infected and has a
large amount of exudate. An appropriate dressing for the nurse to select based on the
wound assessment is:
1. Foam
2. Hydrogel
3. Hydrocolloid
4. Transparent film
ANS: 1
A foam dressing absorbs exudate and debris while maintaining a moist environment.
Topical agents, such as antibiotic ointment, may also be used with a foam dressing. This
would be the most appropriate type of dressing for this wound. A hydrogel dressing
provides moisture to a clean granular wound. A hydrocolloid dressing interacts with the
wound fluid to provide a moist environment. Transparent film protects from friction
injury and may be left in place up to 7 days.
DIF: A
REF: 1313
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
11. A client has a healing abdominal wound. The wound has minimal exudate and collagen
formation. The wound is identified by the nurse as being in which phase of healing?
1. Primary intention
2. Inflammatory phase
3. Proliferative phase
4. Secondary intention
ANS: 3

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During the proliferative phase, the wound fills with granulation tissue (including collagen
formation), the wound contracts, and the wound is resurfaced by epithelialization.
Primary intention is not a phase of wound healing. Wounds that heal by primary intention
have minimal tissue loss, such as a surgical wound. The edges are approximated and the
risk for infection is low. During the inflammatory phase, platelets gather to stop bleeding,
a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris.
Secondary intention is not a phase of wound healing. Wounds that heal by secondary
intention have loss of tissue, such as a pressure ulcer. The wound is left open until it
becomes filled by scar tissue.
DIF: A
REF: 1286
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
12. A client comes to the emergency department following an injury. The nurse implements
appropriate first aid for the client when:
1. Removing any penetrating objects
2. Elevating an affected part that is bleeding
3. Vigorously cleaning areas of abrasion or laceration
4. Keeping any puncture wounds from bleeding
ANS: 2
If a client is bleeding, the nurse applies direct pressure and elevates the affected part.
When a penetrating object is present, it is not removed. Removal could cause massive,
uncontrolled bleeding. Vigorous cleaning can cause bleeding or further injury. Abrasions
and minor lacerations should be rinsed with normal saline and lightly covered with a
dressing. Puncture wounds are allowed to bleed to remove dirt and other contaminants.
DIF: A
REF: 1311
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
13. The nurse is concerned that the clients midsternal wound is at risk for dehiscence. Which
of the following is the best intervention to prevent this complication?
1. Administering antibiotics to prevent infection
2. Using appropriate sterile technique when changing the dressing
3. Keeping sterile towels and extra dressing supplies near the clients bed
4. Placing a pillow over the incision site when the client is deep breathing or coughing
ANS: 4

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A strategy to prevent dehiscence is to use a folded thin blanket or pillow placed over an
abdominal wound when the client is coughing. This provides a splint to the area,
supporting the healing tissue when coughing increases the intraabdominal pressure. A
client who has an infection is at risk for poor wound healing and dehiscence. However,
prophylactic use of antibiotics is not the best intervention to prevent dehiscence. Using
appropriate sterile technique is always important to prevent the development of infection
but is not the best intervention to prevent dehiscence.
DIF: A
REF: 1287
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
14. Following a head injury, the client has thin drainage coming from the left ear. The nurse
describes this drainage as:
1. Serous
2. Purulent
3. Cerebrospinal fluid
4. Serosanguineous
ANS: 1
Serous drainage is clear, watery plasma. Purulent drainage is thick, yellow, green, tan, or
brown. Drainage must be tested to determine if it is cerebrospinal fluid. The nurse should
describe the drainage by its appearance (i.e., serous). Serosanguineous drainage is pale,
red, and watery, a mixture of clear and red fluid.
DIF: A
REF: 1287
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
15. Which nursing entry is most complete in describing a clients wound?
1. Wound appears to be healing well. Dressing dry and intact.
2. Wound well approximated with minimal drainage.
3. Drainage size of quarter; wound pink, 4 4s applied.
4. Incisional edges approximated without redness or drainage; two 4 4s applied.
ANS: 4
This is the most complete description of the clients wound. It describes the wound
according to characteristics observed and the dressing that covers it. Wounds should be
measured using the metric system, not described as the size of objects.
DIF: A
REF: 1307
OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems

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16. The nurse recognizes that skin integrity can be compromised by being exposed to body
fluids. The greatest risk exists for the client who has exposure to:
1. Urine
2. Purulent exudates
3. Pancreatic fluids
4. Serosanguineous drainage
ANS: 3
Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown.
Exposure to urine, bile, stool, acetic fluid, and purulent wound exudates carries a
moderate risk for skin breakdown. Serosanguineous drainage is not caustic to the skin,
and the risk for skin breakdown from exposure to this fluid is low.
DIF: A
REF: 1287
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
17. The client is scheduled for a dressing change. When removing the adhesive tape used to
secure the dressing, the nurse should lift the edge and hold the tape:
1. At a 45-degree angle to the skin surface while pulling away from the wound
2. At a right angle to the skin surface while pulling toward the wound
3. At a right angle to the skin surface while pulling away from the wound
4. Parallel to the skin surface while pulling toward the wound
ANS: 4
To remove tape safely, the nurse loosens the tape ends and gently pulls the outer end
parallel with the skin surface toward the wound. Tape should not be pulled in a direction
away from the wound because this may cause the wound edges to separate. Holding the
tape at a right angle to the skin surface may pull on the wound bed, causing separation of
wound layers, or may damage the underlying skin.
DIF: A
REF: 1320
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
18. When cleaning a wound, the nurse should:
1. Wash over the wound twice and discard that swab
2. Move from the outer region of the wound toward the center
3. Start at the drainage site and move outward with circular motions
4. Use an antiseptic solution followed by a normal saline rinse
ANS: 3

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To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in
circular rotations outward from a point closest to the drain. The nurse never uses the same
piece of gauze or swab to cleanse across an incision or wound twice. The wound should
be cleansed in a direction from the least contaminated area, such as from the wound to
the surrounding skin. The wound is cleaned from the center region to the outer region. An
antiseptic solution is not used to clean a wound, as it may be cytotoxic.
DIF: A
REF: 1324
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
19. The client has a large, deep wound on the sacral region. The nurse correctly packs the
wound by:
1. Filling two thirds of the wound cavity
2. Leaving saline-soaked folded gauze squares in place
3. Putting the dressing in very tightly
4. Extending only to the upper edge of the wound
ANS: 4
The wound should be packed only until the packing material reaches the surface of the
wound. Wound packing that overlaps onto the wound edges can cause maceration of the
tissue surrounding the wound. It can also impede the proper healing and closing of the
[Link] wound should be packed to the upper edge of the wound to prevent dead
space and the formation of abscesses. The gauze should be saturated with the prescribed
solution, wrung out, unfolded, and lightly packed into the wound. The wound should not
be packed too tightly. Overpacking the wound may cause pressure on the tissue in the
wound bed.
DIF: A
REF: 1319
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
20. The nurse is aware that application of cold is indicated for the client with:
1. Menstrual cramping
2. An infected wound
3. A fractured ankle
4. Degenerative joint disease
ANS: 3

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Direct trauma such as fractures or sprains may be treated with cold. The application of
cold can initially diminish swelling and pain. Application of heat to reduce muscle
tension and reduce pain would be more appropriate for the client with menstrual
cramping. The application of cold is not indicated for the client with an infected wound
because it reduces the blood flow to the area. This would limit the number of
macrophages to clear the area of bacteria and would lessen the nutrient supply to the
already impaired tissue. The effects of heat application would be more beneficial to the
client with degenerative joint disease.
DIF: A
REF: 1335
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
21. The client has a stage IV pressure ulcer. In accordance with the Agency for Healthcare
Research and Quality (AHRQ), the nurse recommends that the client should have a(n):
1. Foam mattress
2. Air-fluidized bed
3. Rotokinetic bed
4. Static support surface
ANS: 2
Air-fluidized beds are recommended for clients with burns or multiple stage III or stage
IV pressure ulcers. A foam mattress is recommended for pressure reduction in clients at
high risk for developing a pressure ulcer. A Rotokinetic bed is recommended for clients
who are at risk for or have developed atelectasis and/or pneumonia. A static support
surface is not recommended for a client with a stage IV ulcer. It is used for clients at high
risk for developing a pressure ulcer.
DIF: A
REF: 1305
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
22. The nurse uses the Norton scale in the extended care facility to determine the clients risk
for pressure ulcer development. Which one of the following scores, based on this scale,
places the client at the highest level of risk?
1. 6
2. 8
3. 15
4. 19
ANS: 1
According to the Norton scale, a lower score indicates a higher risk for pressure ulcer
development. The total score ranges from 5 to 20. The client at highest risk would be the
client with a score of 6.

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48-11

DIF: A
REF: 1288
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
23. The client requires support, and an abdominal binder is ordered. The nurse correctly
implements the use of a binder by:
1. Using it as a replacement for underlying dressings
2. Keeping it loose for client comfort
3. Having the client sit or stand when it is applied
4. Making sure the client has adequate ventilatory capacity
ANS: 4
After applying the binder, the nurse should assess the clients ability to ventilate properly,
including deep breathing and coughing. Wounds should be entirely covered with
dressings; the binder is applied over the dressing. The binder should not be loose, or it
will be ineffective in providing support. The client should be lying supine with head
slightly elevated and knees slightly flexed for application of the abdominal binder.
DIF: A
REF: 1328-1329
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
24. The client is brought into the emergency department with a knife wound. The nurse
correctly documents the clients wound as a(n):
1. Contusion wound
2. Clean wound
3. Acute wound
4. Intentional wound
ANS: 3
A client with a knife wound is an example of an acute wound. An acute wound is caused
by trauma from a sharp object. A contusion is a closed wound caused by a blow to the
body by a blunt object, resulting in a bruise. A clean wound is a wound that contains no
pathogenic organisms, such as a closed surgical wound that does not enter the
gastrointestinal, respiratory, or genitourinary system. An intentional wound is a wound
resulting from therapy, such as a surgical incision.
DIF: A
REF: 1294
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
25. The nurse is planning a program on wound healing and includes information that
smoking influences healing by:
1. Suppressing protein synthesis

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2. Creating increased tissue fragility

3. Depressing bone marrow function
4. Reducing functional hemoglobin in the blood
ANS: 4
Smoking reduces the amount of functional hemoglobin in the blood, thus decreasing
tissue oxygenation. Antiinflammatory drugs suppress protein synthesis. Radiation creates
tissue fragility. Chemotherapeutic drugs can depress bone marrow function.
DIF: A
REF: 1311
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
26. To reduce pressure points that may lead to pressure ulcers, the nurse should:
1. Position the client directly on the trochanter when side-lying
2. Use a donut device for the client when sitting up
3. Elevate the head of the bed as little as possible
4. Massage over the bony prominences
ANS: 3
Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure
ulcer development from shearing forces. The client should not be positioned directly on
the trochanter because this can create pressure over the bony prominence. Donut-shaped
cushions are contraindicated because they reduce blood supply to the area, resulting in
wider areas of ischemia. Bony prominences should not be massaged. Massaging
reddened areas increases breaks in the capillaries in the underlying tissues and increases
the risk for injury to underlying tissue and pressure ulcer formation.
DIF: A
REF: 1302
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
27. The client is experiencing low back pain and is to have an aquathermia pad applied. The
nurse recognizes that safe application of heat to a clients injury includes:
1. Providing a timer for the client
2. Allowing the client to adjust the temperature for comfort
3. Placing the pad directly onto the area requiring treatment
4. Using the highest temperature that is tolerated by the client
ANS: 1

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An application should last only 20 to 30 minutes. Providing a timer for the client will
help prevent injury to the tissue. The temperature setting is fixed by inserting a plastic
key into the temperature regulator. In many institutions the central supply room sets the
regulators to the recommended temperature. The nurse does not place the pad directly on
the clients skin. To prevent injury, it should be covered with a thin towel or pillow case.
The recommended temperature is 105 to 110 F. The pad should not be used at the
highest temperature that is tolerated by the client.
DIF: A
REF: 1338
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
28. In reviewing the clients nutritional intake, the nurse wants to recommend intake of foods
that will specifically promote collagen synthesis and capillary wall integrity. The nurse
suggests that the client eat:
1. Fish
2. Eggs
3. Liver
4. Citrus fruits
ANS: 4
Citrus fruits contain vitamin C, which is important in collagen synthesis, capillary wall
integrity, and fibroblast function. Fish and eggs contain protein and vitamin E. Protein
plays a role in neogenesis, collagen formation, and wound remodeling. Liver contains
vitamin A, which is important in epithelialization and wound closure.
DIF: A
REF: 1310-1311
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
29. A client on the medical unit is taking steroids and also has a wound from a minor injury.
To promote wound healing for this client, the nurse recommends that which of the
following be specifically added?
1. Iron
2. Folic acid
3. Vitamin A
4. B complex vitamins
ANS: 3
Vitamin A can reverse steroid effects on skin and delayed healing. Iron does not reverse
the effects of steroids. It is important in the transport of oxygen. Folic acid does not
reverse the effects of steroids. It is a B complex vitamin needed for DNA synthesis. The
B complex vitamins do not reverse the effects of steroids. The B vitamins affect growth
and stimulate appetite, lactation, and the gastrointestinal, neurological, and endocrine
systems.

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DIF: A
REF: 1310-1311
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
30. When asked what the role of the skin is in maintaining homeostasis, the answer that
reflects the greatest insight is:
1. Our body needs vitamin D, and without healthy skin we cannot utilize it into a
form we can use.
2. Without skin we would not be able to enjoy the sense of touch that is so important
to us as humans.
3. The skin is a barrier that is really quite good at keeping disease-causing pathogens
from getting into our body.
4. It is the pain with its pain receptors that alert us to danger so that we can take
appropriate action in order to be safe.
ANS: 3
Although it is a sensory organ for pain, temperature, and touch and synthesizes vitamin
D, its primary role is that of a protective barrier against disease-causing organisms.
DIF: C
REF: 1279
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
31. The primary reason an older adult client is more likely to develop a pressure ulcer on the
elbow as compared to a middle-age adult is:
1. A reduced skin elasticity is common in the older adult
2. The attachment between the epidermis and dermis is weaker
3. The older client has less subcutaneous padding on the elbows
4. Older adults have a poor diet that increases risk for pressure ulcers
ANS: 3
Although all the options are related to causes of skin injury in older adults, the
hypodermis decreases in size with age, and so the older client has little subcutaneous
padding over bony prominences; thus they are more prone to skin breakdown.
DIF: C
REF: 1279
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
32. Which of the following interventions is mostly likely to minimize the cause of a pressure
ulcer on the left buttock of a client who is comatose?
1. Turn and position the client at least every 2 hours.
2. Use a lift sheet when moving the client up in the bed.

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3. Change wet, soiled clothing as promptly as it is detected.

4. Keep the head of the clients bed elevated to less than 30 degrees.
ANS: 1
Pressure is the major cause in pressure ulcer formation, and changing the clients position
to minimize the time spent in a particular position will be the best intervention to relieve
the pressure.
DIF: C
REF: 1304
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
33. Which of the following statements made by the nurse shows the greatest insight into the
need to manage the risk factors that contribute to the formation of a pressure ulcer?
1. Her diet needs to include more protein and less sugary foods.
2. She needs to be moved more gently and with attention to her skin.
3. We need to decrease the time she spends with the weight of her body resting on
her hip
4. The urinary incontinency makes the risk for developing a pressure ulcer so much
greater for her.
ANS: 3
Pressure is the major cause in pressure ulcer formation. Three pressure-related factors
contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration,
and (3) tissue tolerance. The remaining options, although related to contributing factors,
do not address the primary factor, pressure.
DIF: C
REF: 1304
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
34. Which of the following statements made by the nurse shows the most thorough
understanding of the therapeutic value of testing a reddened area on the heel of a
mobility-impaired client for blanching?
1. If it blanches, the problem isnt too bad.
2. When it stays red, the damage is great.
3. Nonblanching hyperemia is a poor indictor of healing.
4. Blanching denotes an attempt to deliver blood to the site.
ANS: 4
If the area blanches (turns lighter in color) and the erythema returns when you remove
your finger, the hyperemia is transient and is an attempt to overcome the ischemic
episode, thus called blanching hyperemia. If, however, the erythemic area does not blanch
(nonblanching erythema) when you apply pressure, deep tissue damage is probable.
DIF:

REF: 1280

OBJ: Analysis

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TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
35. Which of the following nursing documentation best reflects the observable assessment of
skin breakdown on the heel of an African American client?
1. 2-cm area of scaly, dry skin located on the clients right heel.
2. 2-cm area of nonblanching erythema located on the clients right heel.
3. 2-cm area purplish blue in color surrounded by lighter-colored skin located on
right heel.
4. 2-cm area of blanching erythema located on the clients right heel; entire foot
warm to the touch.
ANS: 3
In dark-skinned individuals areas of pressure appear darker than surrounding skin and
have a purplish/bluish hue; the temperature of the area may be warm or cool to the touch.
The remaining options use descriptives not applicable to the dark-skinned individual or
less definite indicators.
DIF: C
REF: 1281
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
36. When changing the soiled linen on the bed of a client who is comatose, the nurse notices
a reddened, blanchable area approximately 2 cm in diameter on her left buttock. The
nurses initial skin breakdown intervention is to:
1. Position the client on her right side
2. Finish providing fresh, dry linen to the clients bed
3. Include a 2-hour turning schedule in the clients care plan
4. Measure the area in order to describe it in the nurses' notes
ANS: 1
Pressure is the major cause in pressure ulcer formation, and changing the clients position
to minimize the time spent in a particular position will be the best intervention to relieve
the pressure. The remaining options are appropriate, but none has priority over proper
positioning of the client.
DIF: C
REF: 1304
OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
37. Although all of the following represent poor transfer techniques, which is most likely to
result in a shearing injury to the skin of an older adult client?
1. Only one staff member positioning an immobile client
2. Allowing the heels to be dragged as the client is being positioned

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3. Failing to lower the head of the bed before moving the client upward
4. Neglecting to use a lift sheet when moving the client to the head of the bed
ANS: 3
Shear is the force exerted parallel to skin resulting from both gravity pushing down on
the body and resistance (friction) between the client and a surface. The remaining options
result in friction damage to the clients skin.
DIF: C
REF: 1281
OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
38. Which of the following clients has the greatest risk for friction-induced skin breakdown?
1. A client who is obese and is frequently incontinent of both urine and feces
2. A client who insists she is comfortable only when positioned on her left side
3. A client who is cognitively impaired and comforts herself by wringing her hands
4. An immobile client who slides down in the recliner where he spends the morning
hours
ANS: 3
A friction injury occurs in clients who are restless or in those who have uncontrollable
movements or any repetitive skin-against-skin motion. The other options represent
friction or moisture factors that contribute to skin breakdown.
DIF: C
REF: 1281
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
39. A cognitively impaired client spends hours a day involuntarily wringing her hands.
Which of the following interventions is the most therapeutic as a means of minimizing
this clients risk for friction damage to her hands?
1. Placing thin cotton mitts on her hands
2. Frequently distracting her with conversation
3. Regularly reminding her to stop wringing her hands
4. Getting a prescription to minimize the compulsive behavior
ANS: 1
A friction injury occurs in clients who are restless or in those who have uncontrollable
movements or any repetitive skin-against-skin motion. The remaining options are not as
likely to be effective with a cognitively impaired client.
DIF: C
REF: 1281
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems

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40. Which of the following assessment findings is most representative of a stage II pressure
ulcer?
1. A blister
2. Undermining
3. Nonblanchable redness
4. Visible subcutaneous fat
ANS: 1
Stage II ulcers have partial-thickness skin loss involving the epidermis, dermis, or both.
The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
The remaining options describe elements of stage I and stage III ulcers.
DIF: A
REF: 1282
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
41. Which of the following statements shows the greatest understanding of wound staging?
1. An ulcer must involve broken skin in order to be staged.
2. A wound that contains slough is difficult to stage.
3. This wound cant be staged until its debrided.
4. The health care provider will need to stage the ulcer.
ANS: 3
An unstageable ulcer is a full-thickness tissue loss in which the base of the ulcer is
covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or
black) in the wound bed. Until enough slough and/or eschar is removed to expose the
base of the wound, the true depth and therefore the stage cannot be determined. The
remaining options are not correct.
DIF: C
REF: 1282
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
42. Granulated tissue is best described as:
1. Soft, yellow, and stringy
2. Black, hard, and necrotic
3. Red, moist, and vascular-rich
4. Yellow, spongy, and sinewy
ANS: 3
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of
which indicates progression toward healing. Soft, yellow or white tissue is characteristic
of slough (stringy substance attached to wound bed), and you will need to remove this
before the wound is able to heal. Black or brown necrotic tissue is eschar, which you will
also need to remove before healing can proceed.

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DIF: A
REF: 1282
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
43. Wounds that are contaminated or infected heal by:
1. Secondary intention
2. Tertiary intention
3. Primary intention
4. Open intention
ANS: 2
Wounds that are contaminated and require observation for signs of inflammation are left
open for several days. When wound edges are approximated; this is tertiary intention
healing.
DIF: A
REF: 1284
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
44. Wounds that heal by primary intention will most likely:
1. Have minimal scarring
2. Contain infected tissue
3. Present with ragged edges
4. Have portions of missing tissue
ANS: 1
Healing occurs by epithelialization; these wounds heal quickly with minimal scar
formation.
DIF: A
REF: 1284
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
45. The inflammatory stage of healing is characterized by:
1. Throbbing pain
2. Granulation tissue
3. Wound contraction
4. Collagen scarring
ANS: 1
Localized redness, edema, warmth, and throbbing pain are characteristics of the
inflammatory stage of healing.
DIF: A
REF: 1284
TOP: Nursing Process: Assessment

OBJ: Comprehension

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MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
46. The initial nursing intervention for the assessment of external hemorrhaging is:
1. Close monitoring of the wound dressing for bloody drainage
2. Frequent assessment of the clients blood pressure
3. Monitoring of the clients heart rate
4. Redressing of the wound
ANS: 1
The nurse observes dressings covering the wound for bloody drainage.
DIF: A
REF: 1286
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
47. The nurse is assessing a 78-year-old female African-American client with dark skin.
When assessing the skin, the nurse knows to avoid which source of light because it can
cast a bluish hue on the skin, making the assessment difficult?
1. Natural sunlight
2. Halogen light
3. Florescent light
4. Incandescent light
ANS: 3
The nurse should avoid a fluorescent light source when assessing dark skin because it
casts a bluish hue, making accurate assessment difficult.
DIF: B
REF: 1295
OBJ: Application
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
48. Which of the following clients is most at risk for developing a pressure ulcer?
1. 3-year-old in Bucks traction
2. 33-year-old comatose client
3. 76-year-old client who has had a mild stroke
4. 38-week-old infant in an oxygen hood
ANS: 2
Clients in a coma cannot perceive pressure and are unable to move voluntarily to relieve
pressure.
DIF: A
REF: 1288-1289
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
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49. A client presents with a pressure ulcer that the nurse is documenting in the medical
record. The nurse notes necrotic tissue on the pressure ulcer, which indicates that:
1. The pressure ulcer is automatically a stage IV
2. The pressure ulcer cannot be staged
3. The client has been abused
4. The pressure ulcer is healing
ANS: 2
Staging systems for pressure ulcers are based on describing the depth of tissue destroyed.
Accurate staging requires knowledge of the skin layers, and a major drawback of a
staging system is that you cannot stage an ulcer covered with necrotic tissue because the
necrotic tissue is covering the depth of the ulcer. The necrotic tissue must be debrided or
removed to expose the wound base to allow for assessment. The necrotic tissue present
on the pressure ulcer doesnt necessarily indicate that the client has been abused, nor does
it indicate that the wound is healing.
DIF: A
REF: 1282
OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
50. The nurse is assessing the pressure ulcer of a 68-year-old female client. Which of the
following would indicate to the nurse that healing is taking place?
1. Eschar
2. Slough
3. Granulation tissue
4. Exudate
ANS: 3
Granulation tissue is red moist tissue composed of new blood vessels, the presence of
which indicates progression toward healing. Black or brown necrotic tissue is eschar
which you will need to remove before healing can proceed. Soft, yellow or white tissue is
characteristic of slough (stringy substance attached to wound bed), and you will need to
remove this before the wound is able to heal. Wound exudate describes the amount, color,
consistency, and odor of wound drainage and is part of the wound assessment. Excessive
exudate indicates the presence of infection. The presence of exudate on the skin
surrounding the wound is indicative of wound deterioration.
DIF: B
REF: 1282
OBJ: Application
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems

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51. The nursing student is bathing a 73-year-old Native American female client. The student
reports to the nurse that the client has what looks like cyanosis on her sacrum. The nurse
goes with the student to assess the client but suspects that the cyanosis that the student
sees is most likely:
1. Caused from the client laying on her back most of the morning
2. Caused by the bright sunlight in the room
3. Normal hyperpigmentation of mongolian spots
4. Blue dye that has bled off the cheap new gowns that the hospital has purchased
ANS: 3
The nurse should not confuse the normal hyperpigmentation of mongolian spots that are
seen on the sacrum of African, Native American, and Asian clients as cyanosis. Observe
the clients skin in nonglare daylight. The Gaskins Nursing Assessment of Skin Color
(GNASC) is a useful tool for assessment for identifying changes in skin color that
increase the clients risk for pressure ulcers.
DIF: A
REF: 1281
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
52. The 23-year-old female client is concerned about scarring from her hernia surgery. She
had a third-degree burn on her right arm when she was younger that left a scar that she is
self-conscious about. Then nurse explains to the client that the wound from the burn
healed differently than the surgical incision will heal. The incision that she will have will
heal by:
1. Primary intention
2. Secondary intention
3. Tertiary intention
4. Dehiscence
ANS: 1
The surgical wound heals by primary intention. The skin edges are approximated, or
closed, and the risk for infection is low. Healing occurs quickly; with minimal scar
formation, as long as infection and secondary breakdown is prevented. Healing occurs by
epithelialization. A wound involving loss of tissue, such as a burn, pressure ulcer, or
severe laceration, heals by secondary intention. The wound is left open until it becomes
filled by scar tissue. It takes longer for a wound to heal by secondary intention, and thus
the chance of infection is greater. In tertiary intention, a wound is left open for several
days, then wound edges are approximated. This type of healing is for wounds that are
contaminated and require observation for signs of inflammation. Closure of wound is
delayed until risk for infection is resolved. When a wound fails to heal properly, the
layers of skin and tissue separate. This most commonly occurs before collagen formation
(3 to 11 days after injury). Dehiscence is the partial or total separation of wound layers.
DIF: B
REF: 1282
TOP: Nursing Process: Assessment

OBJ: Application

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MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
53. The nurse notes that the 43-year-old male client has an abrasion on his upper right thigh
that he received 2 days ago when he was involved in a bicycle accident. The abrasion is
red, swollen, warm, and throbbing. The nurse knows that the wound shows signs of
being:
1. Infected
2. In the inflammatory phase of healing
3. In the proliferative phase of healing
4. In the remodeling phase of healing
ANS: 2
The inflammation stage is the bodys reaction to wounding and begins within minutes of
injury and lasts approximately 3 days. The inflammatory response is beneficial, and there
is no value in attempting to cool the area or reduce the swelling unless the swelling
occurs within a closed compartment. Some contaminated or traumatic wounds show signs
of infection early, within 2 to 3 days. The client has a fever, tenderness and pain at the
wound site, and an elevated white blood cell count. The edges of the wound appear
inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green,
or brown color, depending on the causative organism. With the appearance of new blood
vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24
days. The main activities during this phase are the filling of the wound with granulation
tissue, contraction of the wound, and the resurfacing of the wound by epithelialization.
Maturation, the final stage of healing, sometimes takes place for more than a year,
depending on the depth and extent of the wound..
DIF: A
REF: 1282
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
MULTIPLE RESPONSE
1. Which of the following statements best reflects the nurses role in the health and
maintenance of a clients skin? (Select all that apply.)
1. Ill note on the clients care plan to apply lotion to her dry elbows.
2. Im on my way in to turn the client. Will you be able to help me?
3. The ancillary staff tells me that her skin is generally very dry.
4. The pressure ulcer on her hip has really gotten smaller.
5. Can you bring in some scented lotion for your mom?
6. A 1.5-cm reddened area noted on clients left heel.
ANS: 1, 2, 4, 6

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One of the nurses most important responsibilities is to monitor skin integrity and to plan,
implement, and assess interventions to maintain skin integrity. The remaining options do
not reflect nursing interventionsone reflects ancillary staff, and the other does not
really mention the therapeutic role of the request.
DIF: C
REF: 1282
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
2. Which of the following clients have an increased risk for the development of a pressure
ulcer? (Select all that apply.)
1. A 35-year-old motorcycle accident victim who has been comatose for 5 months
2. A 75-year-old client with type 2 diabetes with neuropathy in his feet
3. A 64-year-old client experiencing anorexia after hip replacement surgery
4. A 70-year-old client diagnosed with advanced Alzheimers disease
5. A 40-year-old client with osteoarthritis who has been in bed with the flu
6. A 25-year-old client in the terminal stages of brain cancer
ANS: 1, 2, 3, 4, 6
Any client experiencing decreased mobility, decreased sensory perception, fecal or
urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development. The
only option that does not represent one of the risk factors is the client dealing with the flu.
DIF: C
REF: 1286
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
3. Proper documentation regarding the assessment of a pressure ulcer must include which of
the following information concerning the wound? (Select all the apply.)
1. Presence of pain
2. Depth of damage
3. Length and width
4. Presence of drainage
5. Description of drainage
6. Condition of surrounding tissue
ANS: 2, 3, 4, 5, 6
Assessment includes depth of tissue involvement (staging), type and approximate
percentage of tissue in wound bed, wound dimensions, exudate description, and condition
of surrounding skin. Presence of pain is not a component of this charting.
DIF: C
REF: 1286
OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.