Question 1

Which of the following is an example of healing by secondary intention? (Select all that apply.)

Accepted Answer

-A full-thickness pressure ulcer
-A dog bite
-A burn

Question 2

It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion?

Accepted Answer

-Yellow-tinged drainage
-Temperature 100.3°F (37.94°C)
-Increased complaints of pain at wound site
-White blood cell count 13,000 mm3 (elevated)
-Foul odor noted from previous dressing

Question 3

Which of the following lab results or measurements indicate a risk for impaired wound healing?

Accepted Answer

-A BMI (body mass index) of 35 (elevated)
-Fasting blood glucose of 215 mg/dl (elevated)
-A serum albumin of 2.9 g/dl (decreased)
-A hemoglobin of 10.0 g per dL (decreased)

Question 4

Identify the functions of dressings.

Accepted Answer

-maintaining a moist environment
-control bleeding and drainage
-Protection from outside contaminants and further tissue injury
-increased patient comfort

Question 5

Which of the following regarding removal of the old dressing on a surgical incision are accurate?

Accepted Answer

-If dressing is over a hairy area, remove tape in the direction of hair growth.
-Use caution to avoid tension on any drains that are present.

Question 6

Which of the following is a method of wound debridement?

Accepted Answer

Moist-to-dry dressing

Question 7

The nurse is teaching the NAP in a nursing home about daily routine measures to reduce the incidence of pressure ulcers within the facility. Which of the following should the nurse include in the teaching?

Accepted Answer

-Turning patients at least every 2 hours
-Use of pillow bridging when needed
-Positioning the patient in the 30-degree lateral position
-Using a turn sheet to reposition patients

Question 8

Match the correct type of dressing to the description.
1. The layer of dressing in contact with the wound- primary dressing
2.Least irritating material- dry gauze

Accepted Answer

3.Nonstick; has a shiny appearance and wicks drainage to the center layer- tefla gauze
4. The layer of dressing that provides protection- secondary dressing

Question 9

How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?

Accepted Answer

By compressing the drain reservoir

Question 10

A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure?

Accepted Answer

Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top.

Question 11

A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?

Accepted Answer

Montgomery ties

Question 12

Why does a wound bed need to stay moist?

Accepted Answer

To support healing by enabling granulation tissue to grow

Question 13

A nurse is applying a wound V.A.C. dressing independently for the first time. What action, if made by the nurse, indicates that further instruction is needed in performing this procedure?

Accepted Answer

The nurse applies new gloves, irrigates the wound with normal saline, and then gently blots it dry. The nurse measures the wound, removes and discards gloves, and applies a new pair of gloves. The nurse cuts the foam approximately one-half inch smaller th

Question 14

The nurse may use clean gloves for changing the dressing on which of the following?

Accepted Answer

chronic pressure ulcer

Question 15

The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states the patient has a hematoma on the right knee. The nurse knows to expect to see:

Accepted Answer

A localized collection of blood underneath the tissues that often takes on a bluish discoloration.

Question 16

When is a surgical wound at greatest risk for hemorrhage?

Accepted Answer

During the first 24 to 48 hours after surgery.

Question 17

The nurse inspects all wounds for signs of infection. A contaminated or traumatic wound may show signs of infection:

Accepted Answer

two to three days after injury

Question 18

A patient with lung cancer received radiation therapy to reduce the size of the tumor prior to a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient

Accepted Answer

fluid and electrolyte imbalance

Question 19

The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction?

Accepted Answer

You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling."

Question 20

The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time?

Accepted Answer

Apply sterile saline-soaked towels to the area

Question 21

Which of the following may indicate an increased risk for wound dehiscence?

Accepted Answer

There is an increase in serosanguineous drainage from the wound

Question 22

Which of the following patients is at greatest risk for developing a wound infection?

Accepted Answer

A diabetic obese patient who smokes.

Question 23

The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding?

Accepted Answer

-The nurse instructs the NAP to empty the drain every 8-12 hours or when it is 2/3 full and document the amount as output on the intake and output record
-The nurse ensures the drainage device appears deflated after it is emptied.

Question	Answer
Which of the following is an example of healing by secondary intention? (Select all that apply.)	-A full-thickness pressure ulcer -A dog bite -A burn
It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion?	-Yellow-tinged drainage -Temperature 100.3°F (37.94°C) -Increased complaints of pain at wound site -White blood cell count 13,000 mm3 (elevated) -Foul odor noted from previous dressing
Which of the following lab results or measurements indicate a risk for impaired wound healing?	-A BMI (body mass index) of 35 (elevated) -Fasting blood glucose of 215 mg/dl (elevated) -A serum albumin of 2.9 g/dl (decreased) -A hemoglobin of 10.0 g per dL (decreased)
Identify the functions of dressings.	-maintaining a moist environment -control bleeding and drainage -Protection from outside contaminants and further tissue injury -increased patient comfort
Which of the following regarding removal of the old dressing on a surgical incision are accurate?	-If dressing is over a hairy area, remove tape in the direction of hair growth. -Use caution to avoid tension on any drains that are present.
Which of the following is a method of wound debridement?	Moist-to-dry dressing
The nurse is teaching the NAP in a nursing home about daily routine measures to reduce the incidence of pressure ulcers within the facility. Which of the following should the nurse include in the teaching?	-Turning patients at least every 2 hours -Use of pillow bridging when needed -Positioning the patient in the 30-degree lateral position -Using a turn sheet to reposition patients
Match the correct type of dressing to the description. 1. The layer of dressing in contact with the wound- primary dressing 2.Least irritating material- dry gauze	3.Nonstick; has a shiny appearance and wicks drainage to the center layer- tefla gauze 4. The layer of dressing that provides protection- secondary dressing
How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?	By compressing the drain reservoir
A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure?	Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top.
A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?	Montgomery ties
Why does a wound bed need to stay moist?	To support healing by enabling granulation tissue to grow
A nurse is applying a wound V.A.C. dressing independently for the first time. What action, if made by the nurse, indicates that further instruction is needed in performing this procedure?	The nurse applies new gloves, irrigates the wound with normal saline, and then gently blots it dry. The nurse measures the wound, removes and discards gloves, and applies a new pair of gloves. The nurse cuts the foam approximately one-half inch smaller th
The nurse may use clean gloves for changing the dressing on which of the following?	chronic pressure ulcer
The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states the patient has a hematoma on the right knee. The nurse knows to expect to see:	A localized collection of blood underneath the tissues that often takes on a bluish discoloration.
When is a surgical wound at greatest risk for hemorrhage?	During the first 24 to 48 hours after surgery.
The nurse inspects all wounds for signs of infection. A contaminated or traumatic wound may show signs of infection:	two to three days after injury
A patient with lung cancer received radiation therapy to reduce the size of the tumor prior to a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient	fluid and electrolyte imbalance
The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction?	You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling."
The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time?	Apply sterile saline-soaked towels to the area
Which of the following may indicate an increased risk for wound dehiscence?	There is an increase in serosanguineous drainage from the wound
Which of the following patients is at greatest risk for developing a wound infection?	A diabetic obese patient who smokes.
The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding?	-The nurse instructs the NAP to empty the drain every 8-12 hours or when it is 2/3 full and document the amount as output on the intake and output record -The nurse ensures the drainage device appears deflated after it is emptied.

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wound care exam