#1
Which of the following factors contribute to impaired tissue integrity?
Inadequate nutrition
ExplanationNutritional deficiency hinders tissue repair and maintenance.
#2
Which assessment finding indicates a risk for impaired tissue integrity?
Presence of a pressure ulcer
ExplanationPressure ulcers suggest compromised tissue integrity.
#3
What is the primary goal of wound care?
To accelerate healing
ExplanationWound care aims to expedite the healing process.
#4
Which nursing intervention is appropriate for promoting tissue integrity in a bedridden patient?
Implement a turning schedule
ExplanationRegular turning prevents pressure ulcers in bedridden patients.
#5
Which factor contributes to delayed wound healing?
Smoking
ExplanationSmoking impedes wound healing due to reduced oxygen supply.
#6
What is the recommended position for a patient to minimize pressure on the sacrum and coccyx?
Side-lying position
ExplanationSide-lying position redistributes pressure, reducing sacral and coccygeal strain.
#7
Which intervention helps in maintaining moisture balance in wound care?
Applying a moisture-retentive dressing
ExplanationMoisture-retentive dressings maintain an optimal environment for healing.
#8
What is the most appropriate action to prevent pressure ulcers in a patient confined to a wheelchair?
Encourage frequent position changes
ExplanationRegular position changes alleviate pressure and prevent ulcers.
#9
What is the purpose of debridement in wound care?
To remove dead tissue
ExplanationDebridement clears necrotic tissue, promoting healthy tissue growth.
#10
Which assessment finding indicates a complication of wound healing?
Increase in wound size
ExplanationWound enlargement suggests a failure in the healing process.
#11
Which type of wound exudate indicates an infection?
Purulent
ExplanationPurulent exudate indicates the presence of infection.
#12
What is the rationale behind using a hydrocolloid dressing in wound care?
To promote autolytic debridement
ExplanationHydrocolloid dressings assist in autolytic debridement, aiding in wound cleansing.