BSN 205 Hallmark Final Questions
and Complete Detailed Answers
Which of the following is an example of healing by secondary intention?
A. A Full thickness pressure injury
B. A surgical incision
C. A dog bite
D. A burn
E. A skin tear - Answer: A Full thickness pressure injury
A dog bite
A burn
It is suspected that a patient is developing a wound infection. Which assessment data would support
this conclusion? (Select all that apply.)
A. Yellow-tinged drainage
B. Temperature 100.3°F (37.94°C)
C. Increased complaints of pain at wound site
D. White blood cell count 13,000 mm3 (elevated)
E. Wound edges of pink to normal skin color
F. Foul odor noted from previous dressing - Answer: Foul noted odor
Temp of 100.3
White blood cell count 13,000 mm3 (elevated)
Yellow-tinged drainage
Increased complaints of pain at wound site
Which of the following lab results or measurements indicate a risk for impaired wound healing?
(Select all that apply.)
A hemoglobin of 10.0 g per dL (decreased)
A serum albumin of 2.9 g/dl (decreased)
,Fasting blood glucose of 215 mg/dl (elevated)
A BMI (body mass index) of 35 (elevated)
A white blood cell count of 7000 per mm3 (normal) - Answer: A hemoglobin of 10.0 g per dL
(decreased)
A serum albumin of 2.9 g/dl (decreased)
Fasting blood glucose of 215 mg/dl (elevated)
A BMI (body mass index) of 35 (elevated)
Identify the functions of dressings. (Select all that apply.)
Removing surface bacteria.
Preventing shear.
Protection from outside contaminants and further tissue injury.
Control of bleeding and drainage.
Increased patient comfort.
Maintaining a moist environment. - Answer: Protection from outside contaminants and further
tissue injury.
Control of bleeding and drainage.
Increased patient comfort.
Maintaining a moist environment.
Which of the following regarding removal of the old dressing on a surgical incision are accurate?
(Select all that apply.)
If dressing is over a hairy area, remove tape in the direction of hair growth.
Tape should be pulled parallel to the skin in a direction away from the incision.
Use caution to avoid tension on any drains that are present.
While wearing clean gloves, remove the dressing layers all at one time and discard.
Wear sterile gloves to remove old dressing. - Answer: If dressing is over a hairy area, remove tape in
the direction of hair growth.
Use caution to avoid tension on any drains that are present.
,Which of the following is a method of wound debridement?
Gauze dressing.
Hemovac drain.
Transparent dressing.
Damp-to-dry dressing. - Answer: Damp-to-dry dressing
The nurse is teaching the nursing assistive personnel (NAP) in a nursing home about daily routine
measures to reduce the incidence of pressure injuries within the agency. Which of the following
should the nurse include in the teaching? (Select all that apply.)
Using a turn sheet to reposition patients.
Rubbing reddened bony prominences.
Decreasing patients' fluid intake to decrease incidence of incontinence.
Use of pillow bridging when needed.
Positioning patient in the 30-degree lateral position.
Turning patients at least every 2 hours. - Answer: Using a turn sheet to reposition patients.
Use of pillow bridging when needed.
Positioning patient in the 30-degree lateral position.
Turning patients at least every 2 hours.
How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?
By keeping the drain lower than the insertion site.
By turning the suction on.
By "milking" the tubing.
By compressing the drain reservoir. - Answer: By compressing the drain reservoir.
A nurse is explaining how to perform a dressing change. Which of the following sequences for
changing a surgical wound dressing (wound drain present) indicates that the nurse requires further
education regarding this procedure?
, Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a
circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to
top.
Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision from top to bottom.
Cleanse around drain by using a circular stroke starting near the drain and moving outward.
Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by using the same technique
as for cleansing. Apply loose, woven gauze as contact layer. Place drain sponge (precut gauze)
around drain. Apply additional layers of gauze as needed. Apply thicker woven pad (e.g., ABD or
Surgipad).
Dispose - Answer: Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around
drain by using a circular stroke starting near the drain and moving outward. Clean incision in
direction of bottom to top.
A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?
Paper tape.
Adhesive tape.
Hypoallergenic tape.
Montgomery ties. - Answer: Montgomery Ties
Why does a wound bed need to stay moist?
To prevent excessive fluid loss from the body.
To support healing by enabling granulation tissue to grow.
To determine if the area has reactive hyperemia.
To decrease patient discomfort. - Answer: To support healing by enabling granulation tissue to
grow.
A nurse is applying negative-pressure wound therapy (e.g., wound vacuum-assisted closure [V.A.C.])
independently for the first time. Assuming all other steps are performed correctly, which action, if
made by the nurse, indicates that further instruction is needed in performing this procedure?
and Complete Detailed Answers
Which of the following is an example of healing by secondary intention?
A. A Full thickness pressure injury
B. A surgical incision
C. A dog bite
D. A burn
E. A skin tear - Answer: A Full thickness pressure injury
A dog bite
A burn
It is suspected that a patient is developing a wound infection. Which assessment data would support
this conclusion? (Select all that apply.)
A. Yellow-tinged drainage
B. Temperature 100.3°F (37.94°C)
C. Increased complaints of pain at wound site
D. White blood cell count 13,000 mm3 (elevated)
E. Wound edges of pink to normal skin color
F. Foul odor noted from previous dressing - Answer: Foul noted odor
Temp of 100.3
White blood cell count 13,000 mm3 (elevated)
Yellow-tinged drainage
Increased complaints of pain at wound site
Which of the following lab results or measurements indicate a risk for impaired wound healing?
(Select all that apply.)
A hemoglobin of 10.0 g per dL (decreased)
A serum albumin of 2.9 g/dl (decreased)
,Fasting blood glucose of 215 mg/dl (elevated)
A BMI (body mass index) of 35 (elevated)
A white blood cell count of 7000 per mm3 (normal) - Answer: A hemoglobin of 10.0 g per dL
(decreased)
A serum albumin of 2.9 g/dl (decreased)
Fasting blood glucose of 215 mg/dl (elevated)
A BMI (body mass index) of 35 (elevated)
Identify the functions of dressings. (Select all that apply.)
Removing surface bacteria.
Preventing shear.
Protection from outside contaminants and further tissue injury.
Control of bleeding and drainage.
Increased patient comfort.
Maintaining a moist environment. - Answer: Protection from outside contaminants and further
tissue injury.
Control of bleeding and drainage.
Increased patient comfort.
Maintaining a moist environment.
Which of the following regarding removal of the old dressing on a surgical incision are accurate?
(Select all that apply.)
If dressing is over a hairy area, remove tape in the direction of hair growth.
Tape should be pulled parallel to the skin in a direction away from the incision.
Use caution to avoid tension on any drains that are present.
While wearing clean gloves, remove the dressing layers all at one time and discard.
Wear sterile gloves to remove old dressing. - Answer: If dressing is over a hairy area, remove tape in
the direction of hair growth.
Use caution to avoid tension on any drains that are present.
,Which of the following is a method of wound debridement?
Gauze dressing.
Hemovac drain.
Transparent dressing.
Damp-to-dry dressing. - Answer: Damp-to-dry dressing
The nurse is teaching the nursing assistive personnel (NAP) in a nursing home about daily routine
measures to reduce the incidence of pressure injuries within the agency. Which of the following
should the nurse include in the teaching? (Select all that apply.)
Using a turn sheet to reposition patients.
Rubbing reddened bony prominences.
Decreasing patients' fluid intake to decrease incidence of incontinence.
Use of pillow bridging when needed.
Positioning patient in the 30-degree lateral position.
Turning patients at least every 2 hours. - Answer: Using a turn sheet to reposition patients.
Use of pillow bridging when needed.
Positioning patient in the 30-degree lateral position.
Turning patients at least every 2 hours.
How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?
By keeping the drain lower than the insertion site.
By turning the suction on.
By "milking" the tubing.
By compressing the drain reservoir. - Answer: By compressing the drain reservoir.
A nurse is explaining how to perform a dressing change. Which of the following sequences for
changing a surgical wound dressing (wound drain present) indicates that the nurse requires further
education regarding this procedure?
, Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a
circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to
top.
Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision from top to bottom.
Cleanse around drain by using a circular stroke starting near the drain and moving outward.
Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by using the same technique
as for cleansing. Apply loose, woven gauze as contact layer. Place drain sponge (precut gauze)
around drain. Apply additional layers of gauze as needed. Apply thicker woven pad (e.g., ABD or
Surgipad).
Dispose - Answer: Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around
drain by using a circular stroke starting near the drain and moving outward. Clean incision in
direction of bottom to top.
A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?
Paper tape.
Adhesive tape.
Hypoallergenic tape.
Montgomery ties. - Answer: Montgomery Ties
Why does a wound bed need to stay moist?
To prevent excessive fluid loss from the body.
To support healing by enabling granulation tissue to grow.
To determine if the area has reactive hyperemia.
To decrease patient discomfort. - Answer: To support healing by enabling granulation tissue to
grow.
A nurse is applying negative-pressure wound therapy (e.g., wound vacuum-assisted closure [V.A.C.])
independently for the first time. Assuming all other steps are performed correctly, which action, if
made by the nurse, indicates that further instruction is needed in performing this procedure?
