13 Wound Care

Question 1

1. A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound?

A. Remove the dressing, inspect the wound, and reapply a new dressing.
B. Inspect the wound and reapply the surgical dressing every 2 hours.
C. Inspect the wound, and keep the dressing off until the health care provider arrives.
D. Wait until the health care provider orders the removal of the surgical dressing.

Answer 1

D. Wait until the health care provider orders the removal of the surgical dressing.

Question 2

2. Which wound would be allowed to heal by secondary intention?

A. Cleft lip repair
B. Infected hysterectomy incision
C. Exploratory laparoscopy incision
D. Facial laceration caused by a pocket knife

Answer 2

B. Infected hysterectomy incision

Question 3

3. Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?

A. Taking the patient’s temperature
B. Applying clean gloves
C. Assessing the wound for drainage
D. Assessing the dressing for drainage

Answer 3

B. Applying clean gloves

Question 4

4. Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?

A. Assessing the site for signs of redness or swelling
B. Reporting the presence of wound odor
C. Removing a soiled outer dressing
D. Opening sterile dressings during the dressing change

Answer 4

B. Reporting the presence of wound odor

Question 5

5. The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

A. Osteoarthritis
B. Glaucoma
C. Deafness
D. Diabetes mellitus

Answer 5

D. Diabetes mellitus

Question 6

1. Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?

A. Begin antibiotic therapy before the dressing change.
B. Use appropriate personal protective equipment.
C. Adhere to sterile technique during the intervention.
D. Complete the dressing change in an effective, efficient manner.

Answer 6

B. Use appropriate personal protective equipment.

Question 7

2. The wound bed of a patient’s pressure injury is red. What does this finding indicate to the nurse?

A. Necrotic tissue
B. Presence of slough
C. Granulation tissue
D. Development of an infection

Answer 7

C. Granulation tissue

Question 8

3. Which measurements would the nurse use to calculate the surface area of a patient’s pressure injury?

Answer 8

B. Length and width

Question 9

4. How would the nurse safely apply an enzyme debridement ointment?

A. Daub ointment on dead tissue at the wound edges.
B. Put ointment on a tongue blade, and gently spread it on the center of the wound.
C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
D. Apply a gauze dressing to ensure contact with the ointment.

Answer 9

C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.

Question 10

5. Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient?

A. Reposition the patient at least every 2 hours.
B. Assess the patient’s bony prominences every shift.
C. Educate the family about the importance of healthy skin.
D. Assist the patient in the selection of high-protein foods.

Answer 10

A. Reposition the patient at least every 2 hours.

Question 11

1. A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?

A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
B. Use a distraction technique to divert the patient’s attention during the procedure.
C. Position the patient comfortably before the intervention.
D. Thoroughly explain the procedure to the patient.

Answer 11

A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.

Question 12

2. Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?

A. Begin antibiotic therapy before the dressing change.
B. Use appropriate personal protective equipment (PPE).
C. Adhere to sterile technique during the intervention.
D. Complete the dressing change in an effective, timely way.

Answer 12

B. Use appropriate personal protective equipment (PPE).

Question 13

3. What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?

A. Notify the surgeon of the bleeding.
B. Remove the dressing, and assess the wound.
C. Assess the patient for signs of shock.
D. Further assess the patient and the wound.

Answer 13

D. Further assess the patient and the wound.

Question 14

4. When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?

A. After performing hand hygiene at the start of the procedure
B. Before removing the inner dressing
C. After removing the original dressing materials and performing hand hygiene a second time
D. Just before cleansing the wound with sterile water

Answer 14

C. After removing the original dressing materials and performing hand hygiene a second time

Question 15

5. Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?

A. Cleansing the wound with sterile water
B. Blotting the incision with dry gauze
C. Wearing sterile gloves to cleanse the wound
D. Using a new gauze pad for each stroke while cleansing the wound

Answer 15

D. Using a new gauze pad for each stroke while cleansing the wound

Question 16

. When irrigating a wound, how would the nurse know the right amount of pressure to apply?

A. Calculate the wound size.
B. Follow the general rule of keeping the pressure between 4 and 15 psi.
C. Keep the pressure strong enough to cause moderate pain.
D. Gentle enough that is does not create a splash off of the wound.

Answer 16

B. Follow the general rule of keeping the pressure between 4 and 15 psi.

Question 17

2. Which action should the nurse avoid before irrigating a patient’s foot wound?

A. Assess the patient for a history of allergies to tape and irrigating solution.
B. Review the provider’s orders for the type of irrigating solution to be used.
C. Assess the patient’s pain on a scale of 0 to 10.
D. Warm the irrigant to body temperature in the microwave.

Answer 17

D. Warm the irrigant to body temperature in the microwave.

Question 18

3. Which device is used for wound irrigation?

A. 19-gauge needle attached to a 10-mL syringe
B. 19-gauge needle attached to a 35-mL syringe
C. Sterile container held 30.5 cm (12 inches) above the wound
D. Foley irrigating syringe

Answer 18

B. 19-gauge needle attached to a 35-mL syringe

Question 19

4. Which imaging study or diagnostic test would the nurse review to determine if the pressure injury on a patient’s left heel is infected?

A. White blood cell count
B. Complete blood count
C. X-ray of left foot
D. Culture and sensitivity test

Answer 19

D. Culture and sensitivity test

Question 20

5. A nurse is irrigating a patient’s abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?

A. Drainage that was not present previously
B. Redness at the abdominal suture line
C. Granulation tissue in the wound bed
D. The patient reports less pain

Answer 20

A. Drainage that was not present previously

Question 21

1. The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first?

A. Explain the purpose of the test to the patient.
B. Assess the level of the patient’s pain at the wound site.
C. Assess the patient for signs and symptoms of infection.
D. Review the order to determine the type of specimen to be collected.

Answer 21

D. Review the order to determine the type of specimen to be collected.

Question 22

2. Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture?

A. Collect the specimen while wearing sterile gloves.
B. Collect the specimen after washing the wound with sterile water.
C. Collect the specimen before cleansing the wound.
D. Collect the specimen after administering prescribed pain medication.

Answer 22

A. Collect the specimen while wearing sterile gloves.

Question 23

3. Which question might the nurse ask the patient when an aerobic wound culture has been ordered?

A. “Do you have any pain at the wound site?”
B. “Have you ever collected a specimen from your wound before?”
C. “Have you had any trouble breathing?”
D. “Have your blood counts been high recently?”

Answer 23

A. “Do you have any pain at the wound site?”

Question 24

4. Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly?

A. “Wear sterile gloves when holding the specimen.”
B. “Take this specimen to the lab immediately.”
C. “Borrow a specimen collection kit from another unit if we’re out of them.”
D. “Keep the specimen tube horizontal.”

Answer 24

B. “Take this specimen to the lab immediately.”

Question 25

5. Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?

A. Wearing clean gloves to remove soiled dressings
B. Using a circular motion to cleanse the wound before collecting the specimen
C. Completing the lab requisition form in a timely manner after collecting the specimen
D. Sending the specimen to the lab within 30 minutes of collecting it

Answer 25

A. Wearing clean gloves to remove soiled dressings

Question 26

1. What is the proper method for cleansing the evacuation port of a wound drainage system?

Answer 26

D. Wipe it with an alcohol sponge.

Question 27

2. What is the nursing action to set up suction for a Hemovac drainage system?

A. Set the suction to lowest level possible.
B. Hemovacs are always set to medium suction.
C. Connect to the wall on intermediate suction.
D. Compress the hemovac, creating suction.

Answer 27

D. Compress the hemovac, creating suction.

Question 28

3. When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality?

A. The drainage is odorless.
B. The drainage is straw colored.
C. The patient doesn’t like looking at the drainage tubing.
D. The amount of drainage was greater today than yesterday.

Answer 28

D. The amount of drainage was greater today than yesterday.

Question 29

4. Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site?

A. Attach the tubing to the patient’s gown with a safety pin.
B. Tape the tubing to the patient’s bed.
C. Attach the tubing to the nearest side rail.
D. Loop the tubing through the bed frame.

Answer 29

A. Attach the tubing to the patient’s gown with a safety pin.

Question 30

5. Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?

A. Pinning the tubing to the patient’s hospital gown
B. Compressing the bulb while replacing the port cap
C. Emptying the drainage container only when it is 90% full
D. Placing the drainage container below the wound site

Answer 30

B. Compressing the bulb while replacing the port cap