Nursing Wound Care Exam: Pressure Ulcers, Skin Integrity, Braden Scale, Stage I-IV Ulcers, Moist-to-Dry Dressings, Hydrocolloid, Alginate, Transparent Film, Dressing Changes, Debridement, Edema Management, Figure-Eight Bandages, Montgomery Straps, Abdomin

Nursing Wound Care Exam: Pressure Ulcers, Skin Integrity, Braden Scale, Stage I-IV Ulcers, Moist-to-Dry Dressings, Hydrocolloid, Alginate, Transparent Film, Dressing Changes, Debridement, Edema Management, Figure-Eight Bandages, Montgomery Straps, Abdominal Binders, NAP Delegation, Infection Prevention, Pain Assessment, Surgical Incision Care, Hemostasis, Biofilm, Chronic Wounds, High-Yield NCLEX Review, Patient Safety, Elderly and Immobile Patients Exam Questions Verified and Provided with Complete A+ Graded Rationales Latest Updated 2026 1. The nurse applies a circumferential gauze dressing to a patient's amputated leg. Which method should the nurse use to decrease edema in the extremity? a.Montgomery straps b.An adhesive tape wrap c.A figure-eight wrap d.A circular turns dressing c.A figure-eight wrap The nurse applies a dressing around the extremity using the figure-eight method to avoid restriction of blood flow and main venous return. This allows the dressing to be anchored by wrapping gauze in alternating directions that ascend and descend with oblique, overlapping turns. The terminal end of the dressing is secured with a short piece of tape, taking care not to restrict blood flow in any manner. Montgomery straps are contraindicated for dressing an extremity because the circumference is usually too small to make them practical. Adhesive tape potentially constricts blood flow to the extremity if it is wrapped tightly over itself in a circumferential manner. Circular turns dressings are used on small parts like fingers or toes, but are too constricting to use on larger body parts. 2. The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care tasks should the nurse assign to this staff member? a.Apply the hydrocolloid dressing. b.Assess dimensions of the wound. c.Report visible drainage on the dressing. d.Change the first postoperative dressing. c.Report visible drainage on the dressing. The nurse assigns reporting visible drainage on the dressing to the NAP because this individual is trained to perform this wound care task. It is essential to review what needs to be looked for and what to report back to the nurse. The remaining wound care tasks require critical thinking and nursing judgment, assessment, and evaluation skills that the nurse cannot delegate because he or she owes these duties to the patient. In addition, the nurse avoids delegating the first postoperative dressing change because it is a sterile procedure requiring the same nursing skills and judgment. 3. The nurse plans care for the patient's wound that requires a moist-to-dry dressing. Which should the nurse use for an expected patient outcome several hours after applying a new dressing? a.The patient states that the dressing feels cold. b.The dressing is dry and intact. c.The dressing has bright red drainage. d.The patient states that the pain level is 8 on a scale of 1 to 10. b.The dressing is dry and intact. The nurse uses a moist-to-dry dressing for wound débridement and exudate collection because cellular debris and exudate in a wound bed delay healing. The nurse expects the dressing to absorb wound drainage and to be dry and intact. The dressing should feel cold as the nurse applies the moist gauze, not later. It should absorb drainage, not cause drainage to increase and penetrate the layers of dressing material. Pain rated as 8 on a scale of 1 to 10 is severe and warrants further investigation by the nurse because a dressing should provide patient comfort. 4. The wound care nurse prepares to dress the wounds of four patients. Which wound should receive a transparent film dressing? a.A clean, superficial laceration b.A deep leg ulcer with infection c.A puncture wound with bleeding d.A large laceration over the eyebrow a.A clean, superficial laceration An indication for a transparent film dressing includes a clean, superficial laceration because transparent dressings adhere to wounds and are nonabsorbent. A transparent dressing is contraindicated for a deep ulcer because the dressing is adherent; in addition, a deep ulcer most likely drains exudate or requires débridement, contraindicating the use of the dressing. The nurse avoids using the transparent dressing for the bleeding puncture wound because he or she first applies a pressure dressing to stop the bleeding and then dresses the wound with an absorbent dressing to collect subsequent drainage. Because the dressing is adherent, the nurse avoids using a transparent dressing over a large laceration. The laceration is likely to require sutures or Steri-Strips to close the wound; thus the nurse avoids using a dressing that can pull on the fragile wound edges. 5. The nurse is caring for a patient with a history of chronic respiratory problems who has an abdominal binder in place. Which should the nurse instruct nursing assistive personnel (NAP) to report as an unexpected outcome? a.The skin around the binder is dry without redness or edema. b.The patient experiences difficulty moving around in bed. c.The patient's pain level has changed from 8 to 6 on a scale of 1 to 10. d.The respiratory rate has decreased from 17 to 15 breaths per minute. b.The patient experiences difficulty moving around in bed. The patient's activity should not be hampered by the binder. The nurse needs to assess the patient's ability to move in bed before the binder is applied and reassess after the binder has been in place for a short time.