Chapter 29: Skin Integrity and Wound Care : Fundamentals of Nursing

1. The nurse knows which description would be classified as a closed wound? a. A large bruise on the side of the face b. A surgical incision that is sutured closed c. A puncture wound that is healing d. An abrasion on the leg 2. The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education? a. “The wound will be red.” b. “The wound will have pus.” c. “The wound will be warm.” d. “The wound will need to be treated.” 3. The nurse identifies which type of wounds heal by tertiary intention? a. An acute wound in which the patient has sutures placed when it happened. b. A pressure ulcer that was treated with dressing changes and is healed. c. An acute wound in which surgical glue was used to close the wound. d. A wound that was left open initially and closed later with sutures. 4. The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a “popping sensation” and a wetness in the dressing, the nurse immediately suspects which complication? a. A wound infection b. The stitches came loose c. Wound dehiscence d. Wound crepitus 5. The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do? a. Cover the wound with a sterile gauze pad. b. Cover the wound with a transparent dressing. c. Put pressure on the wound with a sterile gauze pad. d. Cover the wound with gauze soaked with normal saline. 6. The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity? a. Wound will be completely healed in 72 hours. b. Wound will show signs of healing within 2 weeks.