NLE/PRC Integumentary Test (1-5)



Integumentary Test Questions

1. The nurse is changing a dressing and providing wound care. Which activity should she perform first?

a. Assess the drainage in the dressing.
b. Slowly remove the soiled dressing.
c. Wash hands thoroughly.
d. Put on latex gloves.

2. The nurse is caring for a client with skin grafts covering third-degree burns on the arms and legs. During dressing changes, the nurse should be sure to:

a. apply maximum bandages to allow for absorption of drainage.
b. wrap elastic bandages distally to proximally on dependent areas.
c. wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return.
d. remove bandages with clean gloves.

3. Integumentary test question for the nurse who is performing wound care. Which of the following practices violates surgical asepsis?

a. Holding sterile objects above the waist
b. Considering a 1" edge around the sterile field as being contaminated
c. Pouring solution onto a sterile field cloth
d. Opening the outermost flap of a sterile package away from the body

4. A client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse teaches the client about the importance of protecting the skin from ultraviolet light before drug administration and for 8 hours afterward and stresses the need to protect the eyes. After administering medication for photochemotherapy, the client must protect the eyes for:

a. 4 hours.
b. 8 hours.
c. 24 hours.
d. 48 hours.

5. The nurse documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing?

a. Inflammatory
b. Migratory
c. Proliferative
d. Maturation



Integumentary Test
Answers and Rationale

1) C
- When caring for a client, the nurse must first wash her hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed.

2) B
- Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. Maximum bandages should be avoided because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.

3) C
- Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

4) D
- To prevent eye discomfort, the client must protect the eyes for 48 hours after taking medication for photochemotherapy. Protecting the eyes for a shorter period increases the risk of eye injury.

5) B
- The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells, synthesis of scar tissue by fibroblasts, and development of new cells that grow across the wound. In the inflammatory phase, a blood clot forms, epidermis thickens, and an inflammatory reaction occurs in the subcutaneous tissue. During the proliferative phase, the actions of the migratory phase continue and intensify, and granulation tissue fills the wound. In the maturation phase, cells and vessels return to normal and the scab sloughs off.


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