AMSN Wound Care and Skin Integrity

Question 1

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

Accepted Answer

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

Answer

Intact skin with non-blanchable redness

Answer

Full-thickness tissue loss with visible subcutaneous fat

Answer

Full-thickness tissue loss with exposed bone, tendon, or muscle

Question 2

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

Accepted Answer

Signs of wound infection requiring provider notification

Answer

Granulation tissue formation — a sign of healing

Answer

Normal serosanguineous drainage

Answer

Epithelization of the wound bed

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:

Accepted Answer

Primary intention

Answer

Secondary intention

Answer

Tertiary intention

Answer

Eschar formation

Question 4

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

Accepted Answer

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

Answer

Increase the prescribed negative pressure setting

Answer

Remove the dressing and apply a dry gauze dressing

Answer

Discontinue therapy and notify provider immediately

Question 5

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

Accepted Answer

Necrotic eschar that typically requires debridement to assess wound base

Answer

Healthy eschar that should be left intact

Answer

Granulation tissue forming under the crust

Answer

A scab indicating normal wound healing

Question 6

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

Accepted Answer

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

Answer

1 hour if on a standard mattress

Answer

4 hours regardless of mattress type

Answer

6 hours during nighttime hours