Question 1

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

Accepted Answer

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. 
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. B

Question 2

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

Accepted Answer

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 
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 B, C

Question 3

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?

Accepted Answer

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 
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 B

Question 4

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

Accepted Answer

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. 
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 5

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?

Accepted Answer

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." 
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 6

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

Accepted Answer

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

Question 7

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

Accepted Answer

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. 
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 8

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

Accepted Answer

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 
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 9

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

Accepted Answer

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. 
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

Which statement about wound healing is correct?

Accepted Answer

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 
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

Question 11

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

Accepted Answer

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." 
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 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?

Accepted Answer

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 
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 13

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

Accepted Answer

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. 
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 14

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

Accepted Answer

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 
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

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?

Accepted Answer

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 
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 16

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

Accepted Answer

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

Question 17

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.)

Accepted Answer

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 
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 18

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

Accepted Answer

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 
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

Question 19

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

Accepted Answer

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. 
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 20

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?

Accepted Answer

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

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

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

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?

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

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?

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

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

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

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

Which statement about wound healing is correct?

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

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?

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

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

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?

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

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.)

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

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

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?

Foundations of Safe Client Care

Personal Care and Hygiene

Vital Signs and Vital Measurements

Performing an Assessment

Nutrition and Gastrointestinal Tube Therapy

Supporting Mobility and Immobilization

Comfort Care

End-Of-Life Care

Airway and Breathing

Sterile Technique

Medication Administration

Venous Access

Central Venous Access

Bowel Management

Urinary Elimination

Perioperative Care

Advanced Respiratory Management

Advanced Cardiovascular Care

Advanced Neurologic Care

Filters

Exam 16: Wound Care

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

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

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?

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

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?

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

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

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

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

Which statement about wound healing is correct?

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

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?

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

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

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?

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

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.)

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

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

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?

Foundations of Safe Client Care

Personal Care and Hygiene

Vital Signs and Vital Measurements

Performing an Assessment

Nutrition and Gastrointestinal Tube Therapy

Supporting Mobility and Immobilization

Comfort Care

End-Of-Life Care

Airway and Breathing

Sterile Technique

Medication Administration

Venous Access

Central Venous Access

Bowel Management

Urinary Elimination

Perioperative Care

Advanced Respiratory Management

Advanced Cardiovascular Care

Advanced Neurologic Care

Filters