AMSN Wound Care and Skin Integrity 1 — Questions and Answers
Question 1: A patient has a Stage II pressure injury on the sacrum. Which wound characteristic best describes a Stage II pressure injury?
- Intact skin with non-blanchable redness
- Partial-thickness skin loss presenting as a shallow open ulcer or intact/ruptured blister (Correct answer)
- Full-thickness tissue loss with visible subcutaneous fat
- Full-thickness tissue loss with exposed bone, tendon, or muscle
Correct 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.
Question 2: A patient's sacral wound has a foul smell, green exudate, and surrounding erythema. The nurse identifies this as:
- Granulation tissue formation — a sign of healing
- Signs of wound infection requiring provider notification (Correct answer)
- Normal serosanguineous drainage
- Epithelization of the wound bed
Correct 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.
Question 3: 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:
- Secondary intention
- Primary intention (Correct answer)
- Tertiary intention
- Eschar formation
Correct answer: Primary intention
Primary intention (first intention) healing occurs when wound edges are directly approximated (sutured or stapled) with minimal tissue loss and scarring.
Question 4: A patient is receiving negative pressure wound therapy (NPWT/VAC). The nurse notes the therapy has lost suction. The priority action is:
- Increase the prescribed negative pressure setting
- Inspect the dressing for air leaks, reinforce with foam and drape to restore seal (Correct answer)
- Remove the dressing and apply a dry gauze dressing
- Discontinue therapy and notify provider immediately
Correct 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.
Question 5: A patient with a diabetic foot ulcer has a wound covered with a black, hard, leathery crust. The nurse recognizes this as:
- Healthy eschar that should be left intact
- Necrotic eschar that typically requires debridement to assess wound base (Correct answer)
- Granulation tissue forming under the crust
- A scab indicating normal wound healing
Correct 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.
Question 6: To prevent pressure injury development, the nurse should reposition an immobile patient at minimum every:
- 1 hour if on a standard mattress
- 2 hours on a standard mattress, or every 4 hours on a high-specification foam mattress (Correct answer)
- 4 hours regardless of mattress type
- 6 hours during nighttime hours
Correct 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.
AMSN Wound Care and Skin Integrity 1
A patient has a Stage II pressure injury on the sacrum.
Which wound characteristic best describes a Stage II pressure injury?