28.10.0: Review Questions

Review Questions

1 .

What phase of wound healing is characterized by the migration of keratinocytes across the wound’s surface?

1. hemostasis
2. inflammation
3. proliferation
4. maturation

2 .

What process involves the regeneration of the epidermis and the formation of granulation tissue?

1. epithelialization
2. maturation
3. angiogenesis
4. remodeling

3 .

The maturation phase of wound healing begins around week three. How long can it last?

1. twelve months
2. six months
3. sixty days
4. thirty days

4 .

What is the first phase of the wound-healing process?

1. maturation
2. proliferation
3. hemostasis
4. inflammation

5 .

What type of wound closure would most likely occur with a dehisced surgical wound?

1. primary intention
2. secondary intention
3. tertiary intention
4. delayed primary intention

6 .

What are the most common types of wounds? Select all that apply.

1. incision
2. puncture
3. abrasion
4. avulsion

7 .

What is the likeliest barrier to wound healing?

1. exercising three times a week
2. nutritional deficiencies
3. borderline hypertension
4. previous surgeries

8 .

A patient presents with a pressure injury to their right ischial tuberosity. The wound is 3×5 cm wide and 4 cm depth with exposed muscle. What stage would the nurse document for this pressure injury?

1. full-thickness
2. Stage 3
3. Stage 4
4. unstageable

9 .

What does the intense or prolonged pressure of a pressure injury lead to?

1. ischemia and necrosis
2. immobility and paralysis
3. infection and death
4. aphasia and apraxia

10 .

What is the most likely cause of pressure injury development?

1. compromised immunity
2. respiratory conditions
3. immobility
4. obesity

11 .

What are some pressure injury prevention strategies? Select all that apply.

1. use of specialty beds or pillows
2. early assessment screening
3. off-loading bony prominences
4. frequent repositioning

12 .

A nurse asks a nursing student what the purpose of collagenase therapy is. Which explanation best reflects the student’s understanding?

1. “This medication is a debriding agent you apply to a necrotic wound to help prevent infection or biofilm from forming.”
2. “Debriding the wound with this medication allows for the removal of nonviable tissue to facilitate wound progression.”
3. “By applying this topical therapy, you are slowing the healing process of the wound and cleaning the wound at the same time.”
4. “Collagenase is the only therapy available to debride or remove necrotic tissue from a wound.”

13 .

What situation is a clinical implication for debridement therapy?

1. chronic nonhealing wound
2. dry, stable eschar present
3. hemodynamically unstable
4. recent anticoagulant therapy

14 .

What are the types of debridement? Select all that apply.

1. enzymatic
2. mechanical
3. chemical
4. autolytic

15 .

A nurse is assessing a patient’s venous leg ulcer. The wound measures 3 cm × 5 cm and is extremely weepy. What dressing should the nurse select to manage the exudate volume?

1. foam dressing
2. alginate rope
3. transparent film
4. hydrocolloid

16 .

What wound presentation best describes a diabetic foot ulcer?

1. a dry, oval wound on the medial ankle
2. an oval wound with a callus on the plantar foot
3. a weepy, irregularly shaped wound on the calf
4. a punched-out, dry wound on the great toe

17 .

What clinical presentation is contraindicated for hyperbaric oxygen therapy? Select all that apply.

1. a patient arriving at therapy in street clothes
2. a critically ill patient
3. a patient with untreated pneumothorax
4. a claustrophobic patient

18 .

What is an example of data entry that exemplifies a best practice in wound care documentation?

1. “Wound WNL. Dressing changes without complications.”
2. “Stage 2 arterial wound on arm. 4×4 cm. No drainage noted. Dressing changed per order without complications.”
3. “Wound to left calf measures 3×5 cm. Minimal serious drainage noted. Redness to periwound, from 12 to 3 o'clock. Dressing applied per order, no complications.”
4. “Pressure injury to left elbow. Provider notified. Foam dressing applied for prevention. Educated patient to keep arm elevated as much as possible. Will continue to monitor.”

19 .

What characteristics of a wound should be included in the documentation of a wound assessment? Select all that apply.

1. exudate
2. measurements
3. any undermining
4. any noted odor