AMSN Wound Care and Skin Integrity 3

Question 1

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

Accepted Answer

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

Answer

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.

Question 2

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

Accepted Answer

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

Answer

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

Question 3

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

Accepted Answer

Administering prophylactic IV antibiotics within 60 minutes before the surgical incision

Answer

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

Question 4

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

Accepted Answer

Moisture barrier ointment or liquid skin protectant to the periwound area

Answer

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

Question 5

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

Accepted Answer

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

Answer

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.

AMSN - Academy of Medical-Surgical Nurses Practice Test

AMSN - Academy of Medical-Surgical Nurses Practice Test

AMSN Wound Care and Skin Integrity 3