CPNRE Wound Care and Skin Integrity

Question 1

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?

Accepted Answer

Stage II

Answer

Stage I

Answer

Stage III

Answer

Stage IV

Question 2

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?

Accepted Answer

Hydrocolloid dressing to maintain a moist wound environment

Answer

Dry gauze dressing changed twice daily

Answer

Non-adherent silicone dressing

Answer

Dry transparent film dressing

Question 3

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

Accepted Answer

Purulent drainage with increased warmth and periwound erythema

Answer

Serosanguineous drainage on day 2 post-surgery

Answer

Mild periwound erythema within 2 cm of the incision on day 1

Answer

Slight wound edge approximation separation on day 3

Question 4

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

Accepted Answer

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

Answer

Irrigate with hydrogen peroxide to disinfect the wound bed

Answer

Use dry swabs to remove debris before irrigating

Answer

Apply iodine solution to promote granulation tissue growth

Question 5

Which of the following best describes healing by secondary intention?

Accepted Answer

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

Answer

Wound edges are approximated with sutures and the wound heals in a straight line

Answer

A skin graft is placed over the wound to accelerate closure

Answer

Wound edges are brought together with adhesive strips within 24 hours of injury

Question 6

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

Accepted Answer

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

Answer

Massaging bony prominences vigorously to improve circulation

Answer

Applying powder to skin folds to keep them dry

Answer

Using a donut-shaped foam cushion under the coccyx