A photoplethysmograph (PG) measure venous refill tims and assesses the overall srverity of chronic venous insufficiency. What does a refill time of grater than 24 seconds indicate?
Normal finding
Mild venous insufficiency
Severe venous insufficiency
Moderate venous insufficiency
Normal finding
* Refill times greater than 24 seconds are considered normal. ~ In venous reflux, blood foows backward through the veins, causing a decrease in refill time.
Which of the following is not preventive measure for the formatin of soft corns, a common foot lesion?
Change socks and shoes daily
Wear open footwear
Keep the area between the toes dry
Offload w/interdigit foam or gel pads
Change socks and shoes daily
* Soft corn is a common foot lesion characterized by enlarged interphalangeal joint(s) causing friction against the opposing surface. It is aggravated by the tight shoes & ambulation.
Preventive measures for soft corns include:
- Wearing open or properly fitting footwear
- Keeping the area between the toes dry
- Offloading pressure w/interdigit foam or gel pads or lamb's wool
Changing sock and shoes daily is recommended for preventing ___ ___ which are caused by a contagious viral infection, rather than soft corns.
plantar warts
A 70 YO diabetic male present w/a non-healing foot ulcer. The wound has been present for 4 weeks, and a recent swab showed the predence of Pseudomonas aeruginosa. Which of the following evidence-based protocols should br prioritized in the patient's wound care?
Application of maggot debridement therapy
Wet-to-dry dressings
Regular offloading of pressure points w/total contact casting
Initiation of prophylactic antibiotic therapy
Regular offloading of pressure points w/total contact casting
* Offloading pressure from the affected area is critical in DFU mgt. It reduces pressure & shear forces--primary risk factors for ulcer development --and promotes healing by minimizing further tissue trauma.
_____ _____ _____ are not recommended in the absence of clinical signs of infection, as unecessary antibiotic use can lead to resistance.
Prophylactic systemic antibiotics
Which of the following statements regarding the NPUAP classification system for staging pressure ulcers is false?
When documenting healing pressure ulcer, reverse staging is appropriate
Staging should be based on the type of tissue visualized or palpated
Stage I has intact skin w/non-blanchable erythema; Stage II involves partial thickness loss
There are six stages or categories involved
When documenting healing pressure ulcer, reverse staging is appropriate
* Staging is based on the deepest tissue type visible or palpable. Healing is documented without 'reverse staging' (e.g., 'healing stage III w/ 40% granulation tissue')
Which factor is considered when assessing a patient's risk of pressure injury due to nutritional status?
Hight-protein diet
Vitamin C deficiency
Adequate caloric intake
Overhydraton
Vitamin C deficiency
* Vitamin C is essential for collagen synthesis, a vital component of skin & connective tissue repair & maintenance. A deficiency in Vit. C can weaken the skin & underlying tissues, impeding the body's ability to repair itself & increasing suscceptibility to pressure injuriess.
A ____-___ diet is protective agains pressure injuries. ____ is often a key component to nurtional interventions aimed at reducing the risk of Pressure Injuries
high-protein ; protein
What is the primary purpose of using foam dressings in pressure ulcer prevention?
To reduce shear & friction
To debride the wound
To increase moisture at the wound site
To cleanse the wound
To reduce shear & friction
* Foam dressings primarily cushion vulnerable areas to reduce mechanical stresses-shear & friction- that contribute to skin breakdown & pressure ulcer formation.
You are treating a patient w/burn wounds using hydrogel dressings, and the patient reports a sensation of the wound being "too wet" as well as increasing discomfort. What should you do to best address this concern?
Check the dressing application & consider changing to a less moist dressing type if necessary
Apply powder to absorb exxcess moisture
Explain that exccessive moisture is part of the healing process
Increase the frequency of dressing changes to keep the wound drier
Check the dressing application & consider changing to a less moist dressing type if necessary
A patient reports itching & redness after the application of a collagen-based wound dressing. Which of the following actions is most appropriate in this context?
Administer an antihistamine to manage the patient's pruitus
Educate the patient that itching is a typical indication of healing & continue the treatment plan
Remove the collagen dressing & reassess for possible allergic reactions
Cover the dressing with an occlusive layer to preveent air contact
Remove the collagen dressing & reassess for possible allergic reactions
* Although collagen dressings carry a low risk of hypersensitivity, ithing and redness at the application site may indicate allergic contact dermatitis. Removing & reassessing for allergies is essential to prevent further irritation of progression to more severe allergic responses.
How do chronic wounds such as pressure ulcers & dehisced incisions typically heal?
Tertiary intention
Full-thickness wound repair
secondary intention
Primary intention
secondary intention
* Because the wound heals from the bottom up, this preocess is slower and involves prolonges inflammatory and proliferative phases. - Chronic woundsk such as preessure ulcers & dehisced surgical incisions, typically heal by the secondary method.
_________ (also called delayed primary closure) is a method of wound healing where a doctor leaves an open wound for a few days to clean and watch it before closing it with stitches.
Tertiary intention
Full-thickness wounds -
penetrate the epidermis and dermis into subcutaneous tissue. Treatment requires specialized care, beginning with cleaning and debridement. Healing relies on moisture-retentive dressings (e.g., hydrocolloids or collagen) or negative pressure therapy. Severe cases may require surgical closure, skin grafts, or skin substitutes
Wound healing by ____ ____ occurs when the edges of a clean, surgical, or minor lacerated wound are brought closely together and secured using sutures, staples, or surgical glue. This method minimizes tissue loss, drastically speeds up the healing process, and results in a thin, minimal scar
primary intention
Secondary intention
Recommended heaing when a wound's edges cannot be brought together (due to significant tissue loss or infection). Instead of being stitched shut, the wound is left open and must heal naturally from the base upward through the formation of granulation tissue.
A patient has a diabetic foot wound that is superficial & not clinically infected, with no subcutaneous tissue involvement. What is the Wagner grade of this wound?
Grade 3
Grade 2
Grade 0
Grade 1
Grade 1
* On the Wagner Scale, grade 1 indicates a supervicial ulcer w/out subcutaneous tissue involvement or clinical infection.
The ____ ____ is a 6-point grading system (grades 0 to 5) used to classify the depth of diabetic foot ulcers and the presence of tissue death or infection.
Wagner scale
The Wagner scale classifies the __________ of a DFU and the presence of _____ ______ or ______
depth
tissue death ; infection
A 72 YO diabetic pt. present w/ a non-healing foot ulcer. After assessing the wound, you decide to make evidence-based protocol recommendations. What recommendation is supported by research studies & reflects the current standard of care?
Use a silver-containing dressing due to its antimicrobial properties
A wound care specialist is implementing a new wound measurement tool to monitor to healing process. What regulatory considerations should be priritized when implementing the tool?
Ensure the tool aligns with both facility protocols and applicable regulatoru guidelines
What are the preventive measures to prevent the formation of soft corns, a common foot lesion?
- Offload w/interdigit foam or gel pads
- Keep the area between the toes dry
- Wear open footwear
Tertiary Intention
also known as Delayed Primary-intention would healing. This type of healing refers to wounds that are intentionally left open to allow for cleansing and debridement and then closed by the surgeon at a later time.
Which typ of burn extends through the dermis & presents w/obvious blistering?
Second-degree burn
A seconday-degree burn, also call a superficial partial-thickness burn involves the entire epidermis and extends into the papillary layer of the dermis.
Second-degree burn presents with:
- A moist, glossy, exuding surface
- Noticeable blisters
- Skin that blanches under pressure
- High sensitivity to touch due to preserved nerve endings
During discharge teaching, what should a wound care nurse do if a paitent demonstrates a wound care procedure incorrectly?
Correct the mistake and ask for another demonstration
A shallow, open, reddish-pink ulcer w/out slough is noted on the right heel of pt. This would be classified as what stage of ulcer?
Stage II
* This stage of wound is classified a stage II pressure ulcer due to partial-thickness loss of dermis.
Stage II pressure ulcer
present as a shallow, open ulcer w/a red-pink wound bed and no slough.
Whirlpool as a form of hydrotherapy is contraindicated in all of the following conditions, except;
Venous stasis
Dry gengrene
Acute phlebitis
Lower extremity edema
Venous stasis
Whirlpool as a form of hydrotherapy is useful with what conditions:
- Dry gengrene
- Acute phlebitis
- Lower extremity edema
What is most commonly used dressing for traumatic wounds following debridement of necrotic tissue & eschar?
Alginate & hydrofiber dressings
Antibiotic cement or beads
Hydrocolloids used as taping platform
Negative-pressure wound therapy (NPWT) at 75-150 mm Hg
Negative-pressure wound therapy (NPWT) at 75-150 mm Hg
* NPWT at 75-150 mm Hg is the most frequently applied dressing for traumatic wounds after debridement or nectroic tissue and eschar.
NPWT at 75-150 mm Hg is the most frequently used dressing for -
traumatic wounds after debridement or nectroic tissue and eschar.
NPWT creates an evnironment conductive to secondary or tertiary intention healing by:
- Reducing edema & removing exudate & infectious material
- Stimulating granulation tissue formation and improving perfusion
- Providing an occlusive barrier that protects against further contamination
Various wound fillers-such as _____-_____ sponges can be used with nPWT, particularly for infected wounds or those wa high bacterial burden
silver-impregnated sponges
NPWT is contraindicated or impractical for ___, _____ _____, alternaive advanced dressing that reduce bacterial load and facilitate microdebridement may be employed.
small, shallow wounds
For small, shallow wounds where NPWT is impractical alternaive advanced dressing that reduce bacterial load and facilitate microdebridement may be employed. Exmples of this type of dressing are:
Alginate, hydrofiber, etc
A wound care specialist works at a hospital that accepts Medicare patients and has been tasked w/developing new wound care protocols. Which federal law should be considered to ensure compliance when developing these protocols?
Center for Medicate & Medicaid Services (CMS) Conditions of Participation
What is a superficial, elevated, solid skin lesion less than 1 cm in diameter that can vary in color?
Papule
Pustule
Nodule
Vesicle
Papule
* papule is a supercicial, circumscribed, dome-shaped or flat topped palpable lesion elevated above the skin surface and less than 10mm/1cm in diameter. It can vary in color
A _____ is an elvated lesion that contains pus.
pustule
A ______ is an elevated lesion that contains clear fluid and is also under 10mm in diameter.
vesicle
A _____ is a firm lesion that is thicker or deeper than the average plaque or papule.
nodule
Perpheral neuropathy is the primary cause of which condition?
Diabetic foot ulcers
Peripheral arteriall disease (PAD)
Charcot arthropathy
Systemic infection
Diabetic foot ulcers
* PAD is the primary cause of DFU contributing to approximatel 78% of cases.
Osteomyelitis (bone infection) is a contraindication for _________ __________( )_in wound care because the increased blood flow and cellular activity resulting from ___ could exacerbate the infection
electrical stimulation (ES)
ES
How do chronic wounds such as pressure ulcers & dehisced incisions tipically heal?
Full-thickness wound repair
Secondary interntion
Tertiary intentin
Primary intention
Secondary interntion
* Because the wound heals from the bottom up, thiss process is sloer and involves prolonged inflammatory & proliferative phases. REMEMBER: Chronic wounds, such as pressure ulcers and dehisced surgical incisions, typically heal by SECONDARY INTENTION.
Whirlpool as a form of hydrotherapy for the following condition
Venous stasis