NURS 121L-B: Wound Care, Dressing Changes & Sterile Technique
Mastery 2026 |WCU
1. When preparing a sterile field, which action by the nurse represents a direct
violation of surgical asepsis?
A. Opening the outermost flap of a sterile kit away from the body.
B. Reaching across the sterile field to pick up a pair of sterile forceps.
C. Discarding the first 1-2 mL of a sterile solution before pouring it into a container.
D. Maintaining a 1-inch border around the sterile drape that is considered unsterile.
Answer: B
Rationale: Reaching across a sterile field is a violation because dander or microorganisms
from the nurse’s arm or clothing could fall onto the field. All other options are correct
aseptic techniques.
2. A nurse is assessing a patient’s surgical incision and notes a thick, yellow-to-
green discharge with a foul odor. How should the nurse document this finding?
A. Serous drainage
B. Sanguineous drainage
C. Purulent drainage
D. Serosanguineous drainage
Answer: C
Rationale: Purulent drainage is thick and consists of WBCs, dead tissue, and bacteria; it is
often yellow, green, or brown and indicates infection.
,3. Which stage of pressure injury is characterized by full-thickness skin loss
where adipose tissue is visible, but bone, tendon, or muscle are NOT exposed?
A. Stage 2
B. Stage 4
C. Stage 3
D. Unstageable
Answer: C
Rationale: Stage 3 involves full-thickness skin loss where subcutaneous fat (adipose) may
be visible, but deeper structures like bone or muscle are not yet exposed.
4. A nurse is performing a sterile dressing change. After donning sterile gloves,
the nurse accidentally touches the bedside table. What is the most appropriate
next action?
A. Wipe the gloves with an alcohol swab and continue.
B. Remove the contaminated gloves and don a new sterile pair.
C. Continue with the procedure as long as the wound isn’t touched.
D. Apply a second pair of sterile gloves over the contaminated ones.
Answer: B
Rationale: Once a sterile object touches a clean (non-sterile) object, it is contaminated. The
nurse must replace the gloves to maintain surgical asepsis.
5. During a wound assessment, the nurse notes the presence of ‘slough’ in the
wound bed. What does this indicate?
A. Healthy granulating tissue that should be protected.
B. Evidence of a deep tissue injury with intact skin.
C. A sign of epithelialization indicating the wound is closing.
D. Stringy, yellow or white necrotic tissue that must be removed for healing.
Answer: D
, Rationale: Slough is necrotic (dead) tissue that is usually moist, stringy, and yellow, tan, or
gray. It prevents wound healing and often requires debridement.
6. Which type of wound healing occurs when a surgical incision is closed with
sutures or staples, resulting in minimal tissue loss and a fine scar?
A. Tertiary intention
B. Secondary intention
C. Primary intention
D. Delayed primary closure
Answer: C
Rationale: Primary intention occurs when wound edges are approximated (closed) and
there is minimal tissue loss, typical of clean surgical incisions.
7. A patient’s abdominal wound has partially separated, and the nurse observes
internal organs protruding through the opening. What is the immediate
priority?
A. Push the organs back into the abdominal cavity gently.
B. Cover the area with sterile gauze soaked in sterile normal saline.
C. Apply a tight abdominal binder to prevent further protrusion.
D. Leave the wound open to air and call the physician.
Answer: B
Rationale: This is an evisceration. The immediate nursing action is to cover the protruding
organs with sterile, saline-soaked dressings to keep them moist and minimize infection risk
until surgery.
Mastery 2026 |WCU
1. When preparing a sterile field, which action by the nurse represents a direct
violation of surgical asepsis?
A. Opening the outermost flap of a sterile kit away from the body.
B. Reaching across the sterile field to pick up a pair of sterile forceps.
C. Discarding the first 1-2 mL of a sterile solution before pouring it into a container.
D. Maintaining a 1-inch border around the sterile drape that is considered unsterile.
Answer: B
Rationale: Reaching across a sterile field is a violation because dander or microorganisms
from the nurse’s arm or clothing could fall onto the field. All other options are correct
aseptic techniques.
2. A nurse is assessing a patient’s surgical incision and notes a thick, yellow-to-
green discharge with a foul odor. How should the nurse document this finding?
A. Serous drainage
B. Sanguineous drainage
C. Purulent drainage
D. Serosanguineous drainage
Answer: C
Rationale: Purulent drainage is thick and consists of WBCs, dead tissue, and bacteria; it is
often yellow, green, or brown and indicates infection.
,3. Which stage of pressure injury is characterized by full-thickness skin loss
where adipose tissue is visible, but bone, tendon, or muscle are NOT exposed?
A. Stage 2
B. Stage 4
C. Stage 3
D. Unstageable
Answer: C
Rationale: Stage 3 involves full-thickness skin loss where subcutaneous fat (adipose) may
be visible, but deeper structures like bone or muscle are not yet exposed.
4. A nurse is performing a sterile dressing change. After donning sterile gloves,
the nurse accidentally touches the bedside table. What is the most appropriate
next action?
A. Wipe the gloves with an alcohol swab and continue.
B. Remove the contaminated gloves and don a new sterile pair.
C. Continue with the procedure as long as the wound isn’t touched.
D. Apply a second pair of sterile gloves over the contaminated ones.
Answer: B
Rationale: Once a sterile object touches a clean (non-sterile) object, it is contaminated. The
nurse must replace the gloves to maintain surgical asepsis.
5. During a wound assessment, the nurse notes the presence of ‘slough’ in the
wound bed. What does this indicate?
A. Healthy granulating tissue that should be protected.
B. Evidence of a deep tissue injury with intact skin.
C. A sign of epithelialization indicating the wound is closing.
D. Stringy, yellow or white necrotic tissue that must be removed for healing.
Answer: D
, Rationale: Slough is necrotic (dead) tissue that is usually moist, stringy, and yellow, tan, or
gray. It prevents wound healing and often requires debridement.
6. Which type of wound healing occurs when a surgical incision is closed with
sutures or staples, resulting in minimal tissue loss and a fine scar?
A. Tertiary intention
B. Secondary intention
C. Primary intention
D. Delayed primary closure
Answer: C
Rationale: Primary intention occurs when wound edges are approximated (closed) and
there is minimal tissue loss, typical of clean surgical incisions.
7. A patient’s abdominal wound has partially separated, and the nurse observes
internal organs protruding through the opening. What is the immediate
priority?
A. Push the organs back into the abdominal cavity gently.
B. Cover the area with sterile gauze soaked in sterile normal saline.
C. Apply a tight abdominal binder to prevent further protrusion.
D. Leave the wound open to air and call the physician.
Answer: B
Rationale: This is an evisceration. The immediate nursing action is to cover the protruding
organs with sterile, saline-soaked dressings to keep them moist and minimize infection risk
until surgery.
