Wound Care and Skin Integrity Flashcards

A postoperative patient's abdominal wound has separated with the bowel protruding through the incision. The nurse's immediate action is:

Answer: Cover the wound with moist sterile saline gauze, keep the patient supine with knees flexed, and call the provider STAT

Evisceration requires covering exposed bowel with moist sterile saline gauze to prevent drying, keeping the patient still, and calling the surgical team for emergency closure.

A patient with a venous stasis ulcer on the lower leg is prescribed compression therapy. The nurse should apply compression wraps:

Answer: After assessing for arterial insufficiency — do not apply if ABIs are below 0.5

Compression is contraindicated in severe arterial disease (ABI <0.5); assessing ankle-brachial index (ABI) before applying compression prevents dangerous ischemia.

A patient has a wound with red, moist, granulating tissue filling the wound bed. The nurse correctly identifies this as:

Answer: Healthy granulation tissue indicating the wound is healing

Bright red, moist, granulating tissue is healthy new tissue forming during the proliferative phase of wound healing.

Which Braden Scale score indicates the HIGHEST risk for pressure injury development?

Answer: 6

The Braden Scale scores from 6 (lowest possible) to 23 (no risk); a score of 6 indicates the most severe risk for pressure injury across all subscales.

A nurse is debriding a wound using wet-to-dry dressing changes. The nurse understands this method works by:

Answer: Mechanically removing necrotic tissue as the gauze dries and adheres to the wound

Wet-to-dry debridement works mechanically — the moist gauze dries and adheres to necrotic tissue, which is removed when the dressing is changed.

A patient with a surgical wound develops dehiscence (wound separation without organ protrusion). The nurse should:

Answer: Cover with a sterile dressing, notify the provider, and have the patient avoid Valsalva maneuver

Wound dehiscence requires sterile wound coverage, provider notification for possible surgical re-closure, and preventing increased intra-abdominal pressure.