Question 1

The nurse plans care for the patient's wound that requires a moist-to-dry dressing.Which should the nurse use for an expected patient outcome several hours after applying a new dressing?

Accepted Answer

A)   The patient states that the dressing feels cold.
B)   The dressing is dry and intact.
C)   The dressing has bright red drainage.
D)   The patient states that the pain level is 8 on a scale of 1-10. B

Question 2

A _______ is a fungal or bacteria-embedded slimy matrix of proteins and sugars that adhere to the surface of a wound bed.

Accepted Answer

biofilm

Question 3

The nurse inspects a patient's surgical incision and notes dehiscence several inches long.Which is the most important intervention for the nurse to implement?

Accepted Answer

A)   Call for assistance.
B)   Place a sterile moist dressing on the wound.
C)   Apply direct pressure over the wound dressing.
D)   Apply a pressure dressing over the open area. B

Question 4

The nurse prepares to perform a dressing change on an ulcerated area.Which principle does the nurse apply while performing a dressing change?

Accepted Answer

A)   The dead space found in an ulcer should be packed tightly.
B)   The wound should be débrided using multiple dry gauze pads.
C)   The dressing should absorb exudate without damaging the wound bed.
D)   The wound bed should be dried to stimulate granular tissue.

Question 5

The nurse dresses the surgical incision on the patient's elbow.Which method of securing the bandage should the nurse use with this patient?

Accepted Answer

A)   Spiral
B)   Circular
C)   Recurrent
D)   Figure-eight

Question 6

The nurse assigns patient care to nursing assistive personnel (NAP).Which wound care tasks should the nurse assign to this staff member?

Accepted Answer

A)   Apply the hydrocolloid dressing.
B)   Assess dimensions of the wound.
C)   Report visible drainage on the dressing.
D)   Change the first postoperative dressing.

Question 7

The nurse is caring for a patient with a pressure injury.The nurse would expect which of the following outcomes if the patient's wound is healing? (Select all that apply.)

Accepted Answer

A)   Pain intensity is reduced during dressing changes.
B)   The depth of wound is reduced.
C)   The amount of exudate increases.
D)   The amount of necrotic tissue decreases.

Question 8

The wound care nurse prepares wound care supplies.Which patient assessment datum cues the nurse to provide Montgomery straps to promote wound healing?

Accepted Answer

A)   Heavy exudate
B)   Deep laceration
C)   Femoral dressing
D)   Wound dehiscence

Question 9

The nurse is caring for a patient with a history of chronic respiratory problems who has an abdominal binder in place.Which should the nurse instruct nursing assistive personnel (NAP) to report as an unexpected outcome?

Accepted Answer

A)   The skin around the binder is dry without redness or edema.
B)   The patient experiences difficulty moving around in bed.
C)   The patient's pain level has changed from 8 to 6 on a scale of 1-10.
D)   The respiratory rate has decreased from 17 to 15 breaths per minute.

Question 10

The nurse is preparing to change a moist-to-dry dressing on a patient.After correctly identifying the patient, what is the next most appropriate step for the nurse to perform?

Accepted Answer

A)   Assess patient/family's knowledge of the purpose of the dressing change.
B)   Assess the dressing for the presence of drainage.
C)   Ask the patient to rate his or her wound pain.
D)   Review the order for the type of dressing.

Question 11

The nurse needs to apply a dry sterile dressing.Which should the nurse implement first?

Accepted Answer

A)   Inspect the appearance of the wound.
B)   Remove excess moisture from the wound.
C)   Cleanse with sterile saline solution.
D)   Prepare the sterile field for supplies.

Question 12

The nurse is working with a student nurse to provide care to a patient with a pressure injury.The student nurse describes characteristics of an ideal dressing.Which of the following statements indicate the student needs more education? (Select all that apply.)

Accepted Answer

A)   The dressing should keep the wound bed dry.
B)   The dressing can be removed without causing trauma.
C)   The dressing should conform to the body to allow for movement.
D)   Cost should not be a consideration.
E)   Should be easy for the patient to change after discharge.

Question 13

The nurse removes the patient's hydrocolloid dressing and observes minimal clear, watery drainage.Which action should the nurse take at this time?

Accepted Answer

A)   Evaluate for leukocytosis.
B)   Change to foam dressing.
C)   Collaborate with the health care provider.
D)   Document serous drainage.

Question 14

The nurse is caring for a patient who requires a moist-to-dry dressing.Which action by the nurse is appropriate during the procedure?

Accepted Answer

A)   Applies a dry absorbent outer dressing.
B)   Packs flat gauze into the wound bed.
C)   Soaks the wound packing with antiseptic.
D)   Moistens the old dressing before removal.

Question 15

The nurse is preparing to dress an open, shallow wound with a moderate amount of drainage.Nursing care is correct if the nurse chooses which dressing material?

Accepted Answer

A)   Alginate nonwoven
B)   Adhesive transparent dressing
C)   Hydrocolloid adhesive
D)   Foam nonadherent pad

Question 16

The nurse delegates applying a binder over the patient's abdominal incision to nursing assistive personnel (NAP).Which does the nurse include in the NAP's instructions?

Accepted Answer

A)   Start the binder right under the axilla.
B)   Place the patient in a semi-Fowler's position.
C)   Secure the binder with metal fasteners.
D)   Remove the old dressing and apply a binder.

Question 17

A highly absorbent nonwoven material that forms a gel when exposed to wound drainage is called a(n) __________ dressing.

Accepted Answer

The answer of A highly absorbent nonwoven material that forms...

Question 18

The nurse is assisting a patient with putting on an abdominal binder.In which position does the nurse place the patient?

Accepted Answer

A)   Semi-Fowler's
B)   Supine
C)   Prone
D)   High-Fowler's

Question 19

A ______dressing is contraindicated in ischemic wounds with dry eschar and third-degree burns or wounds that tunnel.

Accepted Answer

The answer of A ______dressing is contraindicated in ischemic wounds...

Question 20

The nurse is applying a gauze bandage to hold a dressing on a patient's wrist since the patient is allergic to tape.Which technique would be most appropriate for the nurse to use?

Accepted Answer

A)   Montgomery straps
B)   A 7.6-cm (3-inch)  bandage wrapped proximal to distal
C)   A 2-inch bandage using the spiral wrap technique
D)   A loosely wrapped elastic bandage using a recurrent turn

Exam 27: Dressings, Bandages, and Binders