Wound Care and Skin Integrity Flashcards

A patient with a skin tear on the forearm requires wound care. The nurse should first:

Answer: Gently irrigate with normal saline and approximate the skin flap if viable before dressing

Skin tears should be gently irrigated with saline, with the skin flap repositioned if viable to minimize tissue loss before applying a non-adherent dressing.

A patient undergoing radiation therapy develops moist desquamation of the irradiated skin area. The nurse should:

Answer: Gently cleanse with water, apply moisture barrier, and avoid friction

Moist desquamation from radiation requires gentle cleansing, moisture barrier protection, and avoidance of friction to prevent further injury to fragile skin.

Which intervention is most effective in preventing wound infection in a surgical patient?

Answer: Administering prophylactic IV antibiotics within 60 minutes before the surgical incision

Evidence-based SSI prevention includes administering prophylactic antibiotics within 60 minutes of incision to achieve therapeutic tissue levels at the time of incision.

A patient with a draining wound has periwound skin breakdown from moisture. The nurse should apply which product to protect the surrounding skin?

Answer: Moisture barrier ointment or liquid skin protectant to the periwound area

Moisture barrier ointments or liquid skin protectants create a waterproof barrier over the periwound skin, preventing further maceration from wound exudate.

A patient with a sacral pressure injury has yellow, soft, stringy tissue in the wound bed. The nurse identifies this as:

Answer: Slough — non-viable tissue that impedes healing and may require debridement

Slough is yellow, tan, or green moist necrotic tissue that adheres to the wound bed; it must be debrided as it harbors bacteria and impedes healing.

A nurse is caring for a patient with a dehisced abdominal wound healing by secondary intention with a wound VAC. The nurse understands that the primary goal of secondary intention healing is:

Answer: Gradual filling of the wound with granulation tissue from the base upward

Secondary intention healing allows wounds to fill from the base with granulation tissue; wound contraction and epithelialization occur over time without surgical closure.