NU129 Exam 4 fundamentals study guide UNIT 8: WOUNDS PRE QUIZ 2026 Galen

Exam 4 fundamentals study guide

UNIT 8: WOUNDS PRE QUIZ

Question 1

The nurse observes clear to yellow watery fluid draining from a patient’s wound. How
should this be documented?

 Sanguineous drainage

 Serosanguinous drainage

 Serous drainage

 Purulent drainage ← Incorrect answer chosen

Correct Answer:

Serous drainage

Rationales:

 Serous drainage (Correct): Thin, clear to pale yellow fluid is characteristic of
serous drainage, which is normal in early wound healing.

 Sanguineous drainage: Bright red blood; indicates active bleeding.

 Serosanguinous drainage: Pink-tinged fluid; mixture of blood and serous fluid.

 Purulent drainage: Thick, yellow/green/brown drainage; indicates infection.

Question 2

Which nursing intervention prevents skin breakdown in immobilized patients?

 Restricting movement

 Turning and repositioning ← Correct answer

 Limiting nutrition

 Avoiding fluids

Feedback:

Correct: Relieves pressure and prevents skin breakdown.

Rationales:

,  Turning and repositioning (Correct): Reduces prolonged pressure on bony
prominences, preventing ischemia and tissue breakdown.

 Restricting movement: Increases risk of pressure injuries.

 Limiting nutrition: Poor nutrition delays healing and increases risk of breakdown.

 Avoiding fluids: Leads to dehydration and impaired skin integrity.

Question 3

A patient with a JP drain asks why it is necessary. What is the nurse’s best response?

 “It removes blood and fluid to reduce the risk of infection.” ← Correct answer

 “It keeps the wound moist, promoting tissue regeneration.”

 “It prevents pain by reducing pressure at the site.”

 “It keeps the wound edges approximated for faster healing.”

Feedback:

JP drains remove blood and serous fluid from a surgical site, preventing accumulation that
could delay healing or promote infection.

Rationales:

 Correct: JP drains prevent fluid buildup, which decreases infection risk and
promotes healing.

 Keeps wound moist: Moist wound healing is important, but JP drains do not serve
this purpose.

 Reduces pain: May occur secondarily, but not the primary purpose.

 Approximates wound edges: Sutures or staples do this, not drains.

Question 4

A patient’s wound is covered with thick, black eschar. What does this wound require?

 Debridement ← Correct answer

 Transparent film dressing

 Hydrocolloid dressing

 Negative pressure therapy

,Feedback:

Eschar (dead tissue) prevents healing and must be removed (debrided) to allow for
granulation and new tissue growth.

Rationales:

 Debridement (Correct): Removes necrotic tissue so healing can occur.

 Transparent film: Used for shallow wounds; not appropriate for eschar.

 Hydrocolloid: Maintains moisture but cannot penetrate eschar.

 Negative pressure therapy: Used after wound bed is clean and free of necrosis.

Question 5

The nurse assesses a surgical incision that is red, warm, and draining purulent fluid.
What is the nurse’s priority action?

 Document the findings and continue to monitor

 Notify the healthcare provider of possible infection ← Incorrect answer chosen

 Apply a dry sterile dressing and reassess in 8 hours

 Encourage the patient to increase protein intake

Correct Answer:

Apply a dry sterile dressing and reassess in 8 hours

Rationales:

 Apply a dry sterile dressing (Correct): This is the safest immediate action to
contain drainage and protect the wound until further evaluation.

 Notify the provider: Important, but not the first action. The nurse must stabilize and
protect the wound before calling.

 Document only: Inadequate for signs of infection.

 Increase protein: Supports healing but does not address acute purulent drainage.

Question 6

During wound cleansing of a surgical incision, the nurse should:

 Use one swab for the entire incision line

,  Wipe side-to-side across the wound with one swab

 Cleanse from top to bottom using a new swab each stroke ← Correct answer

 Cleanse directly over the wound repeatedly

Feedback:

Incisions should be cleansed from top to bottom, using a new swab with each stroke, to
avoid contaminating cleaner areas with organisms from dirtier areas.

Rationales:

 Top to bottom with new swabs (Correct): Prevents cross-contamination.

 One swab for entire incision: Spreads bacteria.

 Side-to-side: Moves contaminants across wound.

 Repeated cleansing over wound: Increases irritation and contamination.

Question 7

The nurse is caring for a bedbound patient. Which intervention is most e ective in
preventing pressure injuries?

 Massaging reddened bony areas

 Limiting fluid intake

 Repositioning every 2 hours in bed ← Correct answer

 Applying an occlusive dressing daily

Feedback:

Repositioning every 2 hours reduces prolonged pressure on bony prominences.

Rationales:

 Repositioning (Correct): Primary prevention strategy.

 Massaging redness: Can worsen tissue damage.

 Limiting fluids: Causes dehydration and skin breakdown.

 Occlusive dressing: Not a prevention method for pressure injuries.

Question 8