Wound Care and Skin Integrity Flashcards

A patient has a Stage II pressure injury on the sacrum. Which wound characteristic best describes a Stage II pressure injury?

Answer: Partial-thickness skin loss presenting as a shallow open ulcer or intact/ruptured blister

Stage II pressure injury involves partial-thickness skin loss (epidermis and/or dermis), presenting as a shallow pink/red wound or intact or ruptured serum-filled blister.

A patient's sacral wound has a foul smell, green exudate, and surrounding erythema. The nurse identifies this as:

Answer: Signs of wound infection requiring provider notification

Foul odor, purulent (green/yellow) exudate, and periwound erythema are classic signs of wound infection requiring medical evaluation and possible antibiotic therapy.

The nurse is assessing a patient's surgical wound and notes the wound edges are well-approximated with no drainage. This type of healing is called:

Answer: Primary intention

Primary intention (first intention) healing occurs when wound edges are directly approximated (sutured or stapled) with minimal tissue loss and scarring.

A patient is receiving negative pressure wound therapy (NPWT/VAC). The nurse notes the therapy has lost suction. The priority action is:

Answer: Inspect the dressing for air leaks, reinforce with foam and drape to restore seal

Loss of suction in NPWT is most commonly due to a dressing air leak; inspecting and reinforcing the seal restores therapeutic function without discontinuing treatment.

A patient with a diabetic foot ulcer has a wound covered with a black, hard, leathery crust. The nurse recognizes this as:

Answer: Necrotic eschar that typically requires debridement to assess wound base

Black, hard eschar is necrotic tissue that prevents wound assessment and healing; debridement is generally required unless the wound is on a heel with good perfusion.

To prevent pressure injury development, the nurse should reposition an immobile patient at minimum every:

Answer: 2 hours on a standard mattress, or every 4 hours on a high-specification foam mattress

NPIAP guidelines recommend repositioning every 2 hours on standard mattresses, or every 4 hours on high-specification foam mattresses to relieve pressure.