Chapter 26: Wound Care - Nurselytic

Questions 29

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Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills

Chapter 26 : Wound Care Questions

Question 1 of 5

All of the following are found during your assessment of a surgical wound. Which would concern you the most?

Correct Answer: C

Rationale: Redness, warmth, and swelling around the wound margin are signs of infection, which is most concerning and requires prompt intervention.

Question 2 of 5

Which of these patients is most at risk for developing a pressure injury?

Correct Answer: B

Rationale: The 78-year-old patient has multiple risk factors: immobility, incontinence, and likely poor skin integrity, increasing pressure injury risk.

Question 3 of 5

A patient has a black, hard, leathery scab on his left heel. The stage of this injury is

Correct Answer: D

Rationale: A black, leathery scab (eschar) indicates an unstageable pressure injury, as the depth cannot be assessed due to necrotic tissue.

Question 4 of 5

If a patient had a stage 3 pressure injury, you would expect to see which of the following on assessment?

Correct Answer: D

Rationale: Stage 3 pressure injuries involve full-thickness loss of skin and subcutaneous tissue, often with undermining or tunneling.

Question 5 of 5

While assessing the skin of a patient on bedrest, you notice a pale area over the left hip with a small blister in the center. What action will you take?

Correct Answer: B

Rationale: A pale area with a blister suggests a developing pressure injury, requiring immediate notification of the provider for intervention.

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