BSN 205 Skills ISB Quizzes
Questions and Complete Detailed
Answers
When cleaning a wound during a dressing change, in what direction should the cleansing of the
wound take place?
Outward from the wound in a circular motion.
Towards the wound in a circular motion.
Clean around the wound edge only.
Away from the wound in a linear pattern. - Answer: Correct Answer Outward from the wound in a
circular motion.
What is a reason to use a wet to dry dressing?
To keep the wound moist.
To decrease healing time.
To debride a wound.
To keep the wound from becoming infected. - Answer: Correct! To debride a wound.
Wet-to-dry gauze dressings are mainly intended for use in wound mechanical debridement and in
this purpose they are conceptually distinct from wet-to-dry or wet-to-moist gauze as a primary
dressing in non-infected wounds
The wound vac dressing must be removed and replaced with a sterile dressing if the wound vac is
turned off for more than how many hours?
4
1
2
3 - Answer: Correct! 2 If therapy is off for more than 2 hours, remove the old dressing and irrigate
the wound. Apply an alternative dressing at the direction of the treating clinician.
,What is the most important dietary intake to promote pressure ulcer healing?
Vitamin E
Proteins
Calcium
Carbohydrates - Answer: Correct! Proteins Increased protein levels have been linked to improved
healing rates.
The report of a culture sent on a client's leg wound states "contaminated specimen." Which nursing
action most likely caused the outcome of this wound culture?
Sample was collected from the wound base
Swab included pooled exudate.
Inner ampule at the bottom of the tube was crushed.
Specimen tube cap was placed upside down on a firm dry surface. - Answer: Correct! Swab included
pooled exudate. Pooled exudate is not cultured. These secretions contain a mixture on contaminants
that are not the same as those causing the infection. The sample sound be collected from the base
of the wound.
A client wet-to-moist dressing for a leg wound. What technique should the nurse use when changing
this dressing?
Tape the entire surface of the dressing.
Apply fluffed gauze to the wound bed and saturate with sterile normal saline.
Press moistened fluffed gauze lightly into wound depressions.
Apply a clean dry 4 x 8 pad over the wet fluffed gauze - Answer: Correct! Press moistened fluffed
gauze lightly into wound depressions. Moistened fluffed gauze should be pressed lightly into the
depressions in the wound.
A client has a hydrocolloid dressing over the right greater trochanter area. Which observation
indicates to the nurse that the dressing needs to be changed?
Silk tape applied to window frame the dressing
, Dressing located one third above the wound and two thirds below the wound
Presence of a white blister under the dressing
Dressing changed 1 day ago - Answer: Correct! Presence of a white blister under the dressing The
dressing should be changed if a white blister appears under the dressing.
The nurse is caring for a client with a wound V.A.C. with black foam on the left heel. For what should
the nurse assess when changing the client's dressing?
Amount of wound contraction
Boundary of shallow chronic ulcer
Healing of superficial wound
Improvement in tunneling - Answer: Correct! Amount of wound contraction Black foam has larger
pores and is used to stimulate granulation tissue and wound contraction, so this is what the nurse
would assess.
A newly admitted client has a 3 cm x 5 cm reddened area over the coccyx. What should the nurse do
first for this client?
Raise the head of the bed 45 degrees
Massage the area.
Position the client off this area
Clean the area with hot water - Answer: Correct! Position the client off this area To prevent further
skin damage, the client should be positioned off the reddened area.
The nurse prepares to change a client's sterile wound dressing. Which approach should the nurse
use if the old dressing is sticking to the site?
Moisten the dressing with normal saline
Gently pull on the old dressing away from the wound.
Gently pull on the old dressing toward the wound.
Pick the old dressing off with a pair of sterile forceps. - Answer: Correct! Moisten the dressing with
normal saline If the older dressing adheres to the suture line, wet it with sterile normal saline.
Questions and Complete Detailed
Answers
When cleaning a wound during a dressing change, in what direction should the cleansing of the
wound take place?
Outward from the wound in a circular motion.
Towards the wound in a circular motion.
Clean around the wound edge only.
Away from the wound in a linear pattern. - Answer: Correct Answer Outward from the wound in a
circular motion.
What is a reason to use a wet to dry dressing?
To keep the wound moist.
To decrease healing time.
To debride a wound.
To keep the wound from becoming infected. - Answer: Correct! To debride a wound.
Wet-to-dry gauze dressings are mainly intended for use in wound mechanical debridement and in
this purpose they are conceptually distinct from wet-to-dry or wet-to-moist gauze as a primary
dressing in non-infected wounds
The wound vac dressing must be removed and replaced with a sterile dressing if the wound vac is
turned off for more than how many hours?
4
1
2
3 - Answer: Correct! 2 If therapy is off for more than 2 hours, remove the old dressing and irrigate
the wound. Apply an alternative dressing at the direction of the treating clinician.
,What is the most important dietary intake to promote pressure ulcer healing?
Vitamin E
Proteins
Calcium
Carbohydrates - Answer: Correct! Proteins Increased protein levels have been linked to improved
healing rates.
The report of a culture sent on a client's leg wound states "contaminated specimen." Which nursing
action most likely caused the outcome of this wound culture?
Sample was collected from the wound base
Swab included pooled exudate.
Inner ampule at the bottom of the tube was crushed.
Specimen tube cap was placed upside down on a firm dry surface. - Answer: Correct! Swab included
pooled exudate. Pooled exudate is not cultured. These secretions contain a mixture on contaminants
that are not the same as those causing the infection. The sample sound be collected from the base
of the wound.
A client wet-to-moist dressing for a leg wound. What technique should the nurse use when changing
this dressing?
Tape the entire surface of the dressing.
Apply fluffed gauze to the wound bed and saturate with sterile normal saline.
Press moistened fluffed gauze lightly into wound depressions.
Apply a clean dry 4 x 8 pad over the wet fluffed gauze - Answer: Correct! Press moistened fluffed
gauze lightly into wound depressions. Moistened fluffed gauze should be pressed lightly into the
depressions in the wound.
A client has a hydrocolloid dressing over the right greater trochanter area. Which observation
indicates to the nurse that the dressing needs to be changed?
Silk tape applied to window frame the dressing
, Dressing located one third above the wound and two thirds below the wound
Presence of a white blister under the dressing
Dressing changed 1 day ago - Answer: Correct! Presence of a white blister under the dressing The
dressing should be changed if a white blister appears under the dressing.
The nurse is caring for a client with a wound V.A.C. with black foam on the left heel. For what should
the nurse assess when changing the client's dressing?
Amount of wound contraction
Boundary of shallow chronic ulcer
Healing of superficial wound
Improvement in tunneling - Answer: Correct! Amount of wound contraction Black foam has larger
pores and is used to stimulate granulation tissue and wound contraction, so this is what the nurse
would assess.
A newly admitted client has a 3 cm x 5 cm reddened area over the coccyx. What should the nurse do
first for this client?
Raise the head of the bed 45 degrees
Massage the area.
Position the client off this area
Clean the area with hot water - Answer: Correct! Position the client off this area To prevent further
skin damage, the client should be positioned off the reddened area.
The nurse prepares to change a client's sterile wound dressing. Which approach should the nurse
use if the old dressing is sticking to the site?
Moisten the dressing with normal saline
Gently pull on the old dressing away from the wound.
Gently pull on the old dressing toward the wound.
Pick the old dressing off with a pair of sterile forceps. - Answer: Correct! Moisten the dressing with
normal saline If the older dressing adheres to the suture line, wet it with sterile normal saline.
