NUR 231 FINAL EXAM QUESTIONS AND ANSWERS 2024-2025
BRANDNEW!!//GRADED A+
After setting up a sterile field, putting on sterile gloves, the nurse prepares to clean a patient's surgical
wound. In what direction would the nurse clean the wound?
Top to bottom
Outside to center
Bottom to top
Side to side - answer-Top to bottom
After cleaning a patient's surgical wound, the nurse applies a layer of dry, sterile dressing over the
wound site, and then applies a second layer. What is the purpose of the first layer of gauze?
To act as a wick for drainage
To prevent contamination with microorganisms
To keep the dressing intact
To maintain a sterile field - answer-To act as a wick for drainage
The nurse is removing the dressing from an abdominal surgical wound and notices that the wound edges
are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent
drainage. The chart reports that the incision was clean and dry with approximated edges and staples
intact upon the last assessment. What would be the first recommended nursing intervention in this
situation?
Place the patient in a sitting position to reduce the pressure on the abdomen
Leave the wound open and notify the primary care provider
Assess for pain, shortness of breath, and abdominal pressure
Tell the patient that this is a life-threatening situation and that the primary care provider will be called. -
answer-Assess for pain, shortness of breath, and abdominal pressure
The nurse is changing the dressing on a patient's surgical wound. After the old dressing is removed, the
nurse notices that the patient's skin is red and blistered where the dressing had been secured with tape.
Which of the following would be an appropriate action by the nurse?
Allow the wound to air dry
Notify the primary care provider for further instructions
,Replace the dressing with a smaller one
Replace the dressing with a larger one. - answer-Replace the dressing with a larger one
The nurse is irrigating a patient's wound using sterile technique. When directing the irrigating solution
into the wound, what does the nurse use to collect the solution as it runs out of the wound?
The used wound dressing
Gauze
A sterile basin
A waterproof pad - answer-A sterile basin
The nurse is irrigating a patient's pressure ulcer. How would the nurse know when to stop irrigating the
wound?
When the solution from the wound flows out a red color.
When all the irrigating solution is finished.
When the solution from the wound flows out a pink color
When the solution from the wound flows out clear. - answer-When the solution from the wound flows
out clear.
Which of the following patients would be at greatest risk for developing a pressure ulcer?
An adolescent patient with a cast on the left leg
A patient who is delirious after taking pain medications.
An adult patient who is comatose
An older patient who has COPD. - answer-An adult patient who is comatose
The nurse is assessing a patient's pressure injury and notes that there is full-thickness tissue loss with
undermining, but no bone, tendon, or muscle is exposed. What stage of pressure injury development
has occurred?
Stage III
Stage IV
Stage I
, Stage II - answer-Stage III
The nurse, assessing a patient for pressure injuries, notices that there is stable eschar on the heels of the
patient. What nursing intervention would be performed in this situation?
Remove the eschar by irrigating while using sterile technique.
Report the existence of eschar on the heels to the primary care provider.
Remove the eschar using a gauze pad moistened with sterile saline.
No nursing intervention is needed in this situation. - answer-No nursing intervention is needed in this
situation.
Caring for a patient with a stage III pressure injury, the nurse measures the depth of the wound. Which
of the following is a recommended action for this procedure?
Insert an antimicrobial swab gently into the wound at a 90-degree angle.
Insert a sterile swab gently into the wound and view the direction of the applicator as the hands of a
clock.
Insert a sterile applicator gently into the wound at a 90-degree angle.
Insert a sterile applicator gently into the wound at a 30-degree angle. - answer-Insert a sterile applicator
gently into the wound at a 90-degree angle.
The nurse is assessing a patient's pressure injury for signs of healing. Which of the following is a sign that
the healing process has begun?
Granulation tissue
Sinus tract
Undermining
Tunneling - answer-Granulation tissue
The nurse is packing a patient's pressure injury with a saline moistened dressing. Which of the following
is a recommended step in this procedure?
Press firmly to loosely pack the moistened gauze into the wound.
Apply one dry, sterile gauze pad over the wet gauze.
Clean the wound and dry the surrounding skin with sterile gauze dressings
BRANDNEW!!//GRADED A+
After setting up a sterile field, putting on sterile gloves, the nurse prepares to clean a patient's surgical
wound. In what direction would the nurse clean the wound?
Top to bottom
Outside to center
Bottom to top
Side to side - answer-Top to bottom
After cleaning a patient's surgical wound, the nurse applies a layer of dry, sterile dressing over the
wound site, and then applies a second layer. What is the purpose of the first layer of gauze?
To act as a wick for drainage
To prevent contamination with microorganisms
To keep the dressing intact
To maintain a sterile field - answer-To act as a wick for drainage
The nurse is removing the dressing from an abdominal surgical wound and notices that the wound edges
are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent
drainage. The chart reports that the incision was clean and dry with approximated edges and staples
intact upon the last assessment. What would be the first recommended nursing intervention in this
situation?
Place the patient in a sitting position to reduce the pressure on the abdomen
Leave the wound open and notify the primary care provider
Assess for pain, shortness of breath, and abdominal pressure
Tell the patient that this is a life-threatening situation and that the primary care provider will be called. -
answer-Assess for pain, shortness of breath, and abdominal pressure
The nurse is changing the dressing on a patient's surgical wound. After the old dressing is removed, the
nurse notices that the patient's skin is red and blistered where the dressing had been secured with tape.
Which of the following would be an appropriate action by the nurse?
Allow the wound to air dry
Notify the primary care provider for further instructions
,Replace the dressing with a smaller one
Replace the dressing with a larger one. - answer-Replace the dressing with a larger one
The nurse is irrigating a patient's wound using sterile technique. When directing the irrigating solution
into the wound, what does the nurse use to collect the solution as it runs out of the wound?
The used wound dressing
Gauze
A sterile basin
A waterproof pad - answer-A sterile basin
The nurse is irrigating a patient's pressure ulcer. How would the nurse know when to stop irrigating the
wound?
When the solution from the wound flows out a red color.
When all the irrigating solution is finished.
When the solution from the wound flows out a pink color
When the solution from the wound flows out clear. - answer-When the solution from the wound flows
out clear.
Which of the following patients would be at greatest risk for developing a pressure ulcer?
An adolescent patient with a cast on the left leg
A patient who is delirious after taking pain medications.
An adult patient who is comatose
An older patient who has COPD. - answer-An adult patient who is comatose
The nurse is assessing a patient's pressure injury and notes that there is full-thickness tissue loss with
undermining, but no bone, tendon, or muscle is exposed. What stage of pressure injury development
has occurred?
Stage III
Stage IV
Stage I
, Stage II - answer-Stage III
The nurse, assessing a patient for pressure injuries, notices that there is stable eschar on the heels of the
patient. What nursing intervention would be performed in this situation?
Remove the eschar by irrigating while using sterile technique.
Report the existence of eschar on the heels to the primary care provider.
Remove the eschar using a gauze pad moistened with sterile saline.
No nursing intervention is needed in this situation. - answer-No nursing intervention is needed in this
situation.
Caring for a patient with a stage III pressure injury, the nurse measures the depth of the wound. Which
of the following is a recommended action for this procedure?
Insert an antimicrobial swab gently into the wound at a 90-degree angle.
Insert a sterile swab gently into the wound and view the direction of the applicator as the hands of a
clock.
Insert a sterile applicator gently into the wound at a 90-degree angle.
Insert a sterile applicator gently into the wound at a 30-degree angle. - answer-Insert a sterile applicator
gently into the wound at a 90-degree angle.
The nurse is assessing a patient's pressure injury for signs of healing. Which of the following is a sign that
the healing process has begun?
Granulation tissue
Sinus tract
Undermining
Tunneling - answer-Granulation tissue
The nurse is packing a patient's pressure injury with a saline moistened dressing. Which of the following
is a recommended step in this procedure?
Press firmly to loosely pack the moistened gauze into the wound.
Apply one dry, sterile gauze pad over the wet gauze.
Clean the wound and dry the surrounding skin with sterile gauze dressings
