Wound Care and Skin Integrity Flashcards

A PN is assessing a client's sacral wound and observes a shallow open ulcer with a red-pink wound bed and no slough. How should this wound be staged?

Answer: Stage II

A Stage II pressure injury presents as a shallow open ulcer with a pink or red wound bed. There is partial-thickness loss of skin with no slough or eschar. Stage I involves intact skin with non-blanchable erythema; Stage III involves full-thickness tissue loss.

A client has a Stage III pressure injury on the heel. The wound bed contains 60% yellow slough and 40% granulation tissue. Which type of dressing would best support debridement?

Answer: Hydrocolloid dressing to maintain a moist wound environment

Hydrocolloid dressings maintain a moist wound environment that facilitates autolytic debridement, helping to break down slough. A dry gauze dressing would desiccate the wound and impair healing. Moist wound healing is the standard of care.

When assessing a client's wound for signs of infection, which finding is most indicative of a wound infection?

Answer: Purulent drainage with increased warmth and periwound erythema

Classic signs of wound infection include purulent (pus-containing) drainage, increased warmth, erythema extending beyond the immediate wound edge, swelling, and pain. Serosanguineous drainage and minimal erythema in the first 24–48 hours are normal inflammatory responses.

A PN is performing a wound irrigation. Which of the following techniques is correct?

Answer: Use a 35 mL syringe with a 19-gauge angiocatheter and normal saline

Wound irrigation with a 35 mL syringe and 19-gauge angiocatheter delivers normal saline at the correct pressure (4–15 psi) to remove debris without damaging new tissue. Hydrogen peroxide and iodine are cytotoxic to granulation tissue and should be avoided.

Which of the following best describes healing by secondary intention?

Answer: The wound is left open and heals from the base up through granulation, contraction, and epithelialization

Secondary intention healing occurs when wound edges cannot be approximated (e.g., infected wounds, pressure injuries). The wound heals from the base upward by granulation tissue formation, wound contraction, and epithelialization. This process is slower and leaves more scarring than primary intention.

A client is at high risk for pressure injuries. Which nursing intervention is most effective in preventing skin breakdown?

Answer: Repositioning the client every 2 hours and using a pressure-redistribution surface

Regular repositioning (every 2 hours) relieves prolonged pressure on vulnerable tissue, and pressure-redistribution surfaces (e.g., foam or air mattresses) reduce peak interface pressure. Vigorous massage over bony prominences can damage fragile capillaries. Donut cushions concentrate pressure at the edges and are contraindicated.