NSG 3100 Exam 2 Wound Care questions
and answers
The continuous quality improvement team is monitoring the nursing care of clean-contaminated
wounds. Which operative wound would be excluded from this study?
1. Gastric resection
2. Uncomplicated abdominal hysterectomy
3. Breast biopsy
4. Lung resection - correct answer 3. Breast biopsy
Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary,
genital, or urinary tract has been entered. These wounds show no evidence of infection. A gastric
resection would be included in the study.
The surgical report of a newly transferred client indicates that there was a great deal of intestinal
spillage into the abdominal cavity during the clients bowel resection. For which category of wound
should the receiving nurse plan care for this client?
1. Clean-contaminated
2. Contaminated
3. Dirty
4. Infected - correct answer 2. Contaminated
Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary,
genital, or urinary tract has been entered, but minimal to no spillage has occurred.
A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to
prepare for this clients care?
1. Obtain ice packs to apply to the wounds.
2. Request gauze to pack the wounds.
, 3. Organize suture material to close the wounds.
4. Notify the surgical staff that a surgical client will soon be arriving. - correct answer 1. Obtain ice packs
to apply to the wounds.
Rationale 1: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of
blood vessels. These wounds are treated with ice pack application for the first 24 hours.
After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a
reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure.
One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the
nurse document this area?
1. Reactive hyperemia
2. Stage I pressure ulcer
3. Stage II pressure ulcer
4. Stage III pressure ulcer - correct answer 1. Reactive hyperemia
Rationale 1: If the reddened area blanches with thumb pressure and disappears in one-half to three-
quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to
the skin and tissues has occurred.
The nurse assesses an open area over a clients greater trochanter that is approximately 10 cm in
diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in
toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure
ulcer?
1. There is undermining of adjacent tissues.
2. The crater extends into the subcutaneous tissue.
3. The joint capsule of the hip is visible.
4. The ulcer has thick dark eschar over the top. - correct answer 3. The joint capsule of the hip is visible.
Rationale 1: Undermining of adjacent tissues can occur in either a stage III or stage IV pressure ulcer.
The UAP reports a small skin tear on the clients forearm that occurred during a routine turn. After
assessing the wound the nurse should take which action?
1. Obtain a transparent dressing for the UAP to place on the wound.
2. Request a consult with the wound care nurse.
3. Cleanse the wound and apply a dressing.
and answers
The continuous quality improvement team is monitoring the nursing care of clean-contaminated
wounds. Which operative wound would be excluded from this study?
1. Gastric resection
2. Uncomplicated abdominal hysterectomy
3. Breast biopsy
4. Lung resection - correct answer 3. Breast biopsy
Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary,
genital, or urinary tract has been entered. These wounds show no evidence of infection. A gastric
resection would be included in the study.
The surgical report of a newly transferred client indicates that there was a great deal of intestinal
spillage into the abdominal cavity during the clients bowel resection. For which category of wound
should the receiving nurse plan care for this client?
1. Clean-contaminated
2. Contaminated
3. Dirty
4. Infected - correct answer 2. Contaminated
Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary,
genital, or urinary tract has been entered, but minimal to no spillage has occurred.
A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to
prepare for this clients care?
1. Obtain ice packs to apply to the wounds.
2. Request gauze to pack the wounds.
, 3. Organize suture material to close the wounds.
4. Notify the surgical staff that a surgical client will soon be arriving. - correct answer 1. Obtain ice packs
to apply to the wounds.
Rationale 1: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of
blood vessels. These wounds are treated with ice pack application for the first 24 hours.
After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a
reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure.
One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the
nurse document this area?
1. Reactive hyperemia
2. Stage I pressure ulcer
3. Stage II pressure ulcer
4. Stage III pressure ulcer - correct answer 1. Reactive hyperemia
Rationale 1: If the reddened area blanches with thumb pressure and disappears in one-half to three-
quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to
the skin and tissues has occurred.
The nurse assesses an open area over a clients greater trochanter that is approximately 10 cm in
diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in
toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure
ulcer?
1. There is undermining of adjacent tissues.
2. The crater extends into the subcutaneous tissue.
3. The joint capsule of the hip is visible.
4. The ulcer has thick dark eschar over the top. - correct answer 3. The joint capsule of the hip is visible.
Rationale 1: Undermining of adjacent tissues can occur in either a stage III or stage IV pressure ulcer.
The UAP reports a small skin tear on the clients forearm that occurred during a routine turn. After
assessing the wound the nurse should take which action?
1. Obtain a transparent dressing for the UAP to place on the wound.
2. Request a consult with the wound care nurse.
3. Cleanse the wound and apply a dressing.
