Deck 16: Wound Care

Question 1

The student learning about wounds knows that which statement is true?

A) Partial-thickness wounds go through the entire dermis.
B) Partial-thickness wounds heal mainly by re-epithelialization.
C) Full-thickness wounds can heal only through skin grafting.
D) Full-thickness wounds only extend into the upper dermis.

Answer 1

Partial-thickness wounds heal mainly by re-epithelialization.

Question 2

Which statement about wound healing is correct?

A) Primary intention: occurs only in superficial wounds
B) Secondary intention: wounds that have lost tissue, resulting difficulty pulling wound edges together
C) Delayed primary intention: occurs when healthcare has been delayed too long to close the wound
D) Delayed primary intention: creates the most scar tissue

Answer 2

Secondary intention: wounds that have lost tissue, resulting difficulty pulling wound edges together

Question 3

The nursing student asks for an explanation of "biofilm." What explanation by the faculty is best?

A) Naturally occurring membranous wound covering
B) Complex colony of microorganisms
C) First layer of healing tissue in primary intention
D) A transparent dressing made with organic materials

Answer 3

Complex colony of microorganisms

Question 4

A client is to have a sharps debridement of a wound today. What responsibilities does the nurse have with this client?

A) Cut away dead tissue.
B) Ensure consent form is signed.
C) Apply pain numbing cream.
D) Obtain an anesthetic history.

Question 5

A client had surgery this morning and the incision is covered with a sterile occlusive dressing. When the client rolls over in bed, the dressing peels off. What action by the nurse is best?

A) Assess the wound for dehiscence.
B) Call the surgeon immediately.
C) Replace the dressing using sterile technique.
D) Redress the incision with a gauze pad.

Question 6

The nurse has cleansed and is dressing a circumferential wound on the client's upper arm. What action by the nurse is best?

A) Wrap the dressing with an ACE wrap to keep it from slipping off.
B) Only use short, individual pieces of tape in strategic places.
C) Avoid taping the dressing on the elbow or wrist.
D) Check distal circulation once the dressing is in place.

Question 7

A student is in a wound care clinic and has been removing staples and sutures. What action by the student demonstrates a need for further education?

A) Removes every other staple or suture first
B) Lifts staples out one side of the staple at a time
C) Places wound closure strips side-by-side on the wound so the strips are touching
D) Does not pull exposed suture material through the skin

Question 8

A nurse is caring for a client who has a Penrose drain. What action by the nurse shows good understanding of this type of drain?

A) Uses the large safety pin on the drain to attach the drain to the gown
B) Creates a dressing that will contain the exudate draining from the Penrose
C) Ensures the drain is completely compressed after emptying it
D) Squeezes the sides of the reservoir together when compressing the drain

Question 9

What is an important safety measure related to care of the client with negative pressure wound therapy (NPWT)?

A) Close clamps on tubing and disconnect and drain tubing.
B) Pull the transparent cover dressing off in a lateral direction.
C) Cover the entire wound base with the foam dressing, including any tunnels.
D) Never cut the foam dressing while holding over the client's wound.

Question 10

A client with a venous wound is being discharged home to continue wound care. The client asks the nurse how to prevent future ulcers from occurring. What response by the nurse is best?

A) Stay off your feet as much as possible.
B) Continue to wear your compression hose.
C) Nothing since you already have had one.
D) Soak your lower legs in warm water daily.

Question 11

A client asks the nurse to explain the purpose of an Unna boot. What response by the nurse is best?

A) "It is a compression boot that helps heal diabetic foot ulcers."
B) "They are elastic stocking that squeeze your calves rhythmically."
C) "They help prevent itching and will dry out some of those wounds."
D) "These will protect your lower legs from further injury."

Question 12

A client has a lower leg wound that has a large amount of drainage. What type of dressing will the nurse choose for wound care on this client?

A) Calcium alginate
B) Hydrogel
C) Hydrocolloid
D) Honey alginate

Question 13

A client has a localized area of nonblanchable erythema. What action by the nurse is best?

A) Massage the area with lotion.
B) Provide the client with a heating pad.
C) Begin individualized pressure injury prevention activities.
D) Ask the provider to order a wound nurse consultation.

Question 14

A client's ankle-brachial index (ABI) is 0.85. How does the nurse interpret this finding?

A) At risk for diabetic foot ulcers
B) Moderate peripheral vascular disease
C) At high risk for venous stasis ulcers
D) Increased oxygenation to chronic wound

Question 15

The nurse giving handoff report states that a client had a wound dehiscence. What does the oncoming nurse understand about this condition?

A) Dead or devitalized tissue has been removed.
B) The client has moisture-associated skin damage.
C) The client did not score well on the Monofilament test.
D) A surgical wound has ruptured along suture line.

Question 16

A nurse has designated ambulating a client with a Jackson-Pratt drain to an unlicensed staff member. What action does the nurse take prior to the walk?

A) Takes the client's vital signs
B) Pins the Jackson-Pratt drain to the gown
C) Empties and measures the drainage
D) Checks the client's dressings

Question 17

The nursing student reports that a newly postoperative client has not had any drainage from the Jackson Pratt drain all shift. What response by the nurse is best?

A) "Good, we can pull it out now."
B) "We better call the surgeon."
C) "Is the bulb fully compressed?"
D) "It shouldn't have any drainage."

Question 18

What data would indicate that a priority goal for a client with a wound drain has been met?

A) Less than 50 mL drainage in 24 hours
B) White blood cell count within normal range
C) Denies pain at the drain site
D) Demonstrates drain care before discharge

Question 19

The nurse is performing a Monofilament test on a client. Which actions are appropriate? (Select all that apply.)

A) Let the client feel the filament on the arm first.
B) Press the filament onto the pads of the fingers.
C) Have the client keep his or her eyes closed.
D) Press the filament into the skin until it forms a "C" shape.
E) Avoid testing on callused areas of the feet.

Question 20

The nurse knows that which areas of the body are most prone to pressure injury? (Select all that apply.)

A) Elbows
B) Scapula
C) Ischial tuberosity
D) Heels
E) Sternum

Question 21

What characteristics do dressing material need to work well with secondary-intention wounds? (Select all that apply.)

A) May need to absorb a large amount of exudate
B) May need to get into tunnels under the skin
C) May need to fill the void of the missing tissue
D) May need to add moisture to a dry wound
E) Needs to be occlusive and long-term

Question 22

The nurse providing wound care assesses which characteristics of the wound? (Select all that apply.)

A) Location
B) Length
C) Depth
D) Drainage
E) Color

Question 23

Which types of debridement are matched to correct statements? (Select all that apply.)

A) Autolytic debridement uses moisture from the wound itself
B) Enzymatic: hard tissue must be cross-hatched for effectiveness
C) Ultrasound mist: involves ultrasound-guided irrigations
D) Mechanical: includes wet-to-dry dressings and whirlpools
E) Biological: selectively cleans out only the dead tissue

Question 24

The wound care nurse is preparing a talk on chronic wounds. What information will the nurse provide to distinguish chronic wounds? (Select all that apply.)

A) Tend to be acidic
B) Stalled in inflammatory process
C) Low level of tissue oxygen
D) Colonized by 1 to 2 strains of bacteria
E) Greater potential for biofilms

Question 25

A nurse is assessing a wound using the acronym TIME. The nurse would assess which characteristics? (Select all that apply.)

A) T: Length of Time the wound has been present
B) I: Signs of Infection
C) M: Amount and characteristics of Moisture in the wound
D) E: Estimated time to healing
E) I: Injury or etiology of the wound