NURS 121L-A: Wound Care & Postoperative Management Master Quiz
2026 |WCU
1. A patient’s surgical incision has pulled apart, and the nurse observes that
internal organs are protruding through the opening. Which is the immediate
priority action?
A. Apply a dry sterile dressing and call the surgeon
B. Place the patient in high-Fowler’s position
C. Push the organs back into the abdominal cavity gently
D. Cover the protruding organs with sterile gauze moistened with sterile normal saline
Answer: D
Rationale: Evisceration is a medical emergency. The nurse must cover the organs with
sterile saline-soaked gauze to prevent drying and infection, then notify the surgeon
immediately. The patient should be kept in low-Fowler’s with knees bent.
2. When assessing a pressure injury, the nurse notes full-thickness tissue loss
with visible subcutaneous fat, but bone, tendon, and muscle are not exposed.
How should this be staged?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: B
Rationale: Stage 3 involves full-thickness skin loss involving damage to or necrosis of
subcutaneous tissue that may extend down to, but not through, underlying fascia. Bone,
tendon, and muscle are not visible at this stage.
,3. The nurse is caring for a postoperative patient who has not voided for 8
hours. What is the most appropriate first action?
A. Perform a bladder scan
B. Increase the IV fluid rate
C. Insert a straight catheter immediately
D. Encourage the patient to drink more water
Answer: A
Rationale: A bladder scan is a non-invasive way to assess the volume of urine in the
bladder and confirm urinary retention before proceeding to invasive measures like
catheterization.
4. Which type of wound healing occurs when a surgical incision is closed with
sutures or staples?
A. Primary intention
B. Secondary intention
C. Tertiary intention
D. Granulation
Answer: A
Rationale: Primary intention healing occurs in wounds with minimal tissue loss and well-
approximated edges, such as clean surgical incisions.
5. A nurse is using the Braden Scale to assess a patient’s risk for pressure
injuries. A total score of 12 indicates which risk level?
A. No risk
B. Mild risk
C. Moderate risk
D. High risk
Answer: D
, Rationale: On the Braden Scale, a score of 12 or less generally indicates high risk (10-12 =
high risk, <9 = very high risk). Lower scores indicate higher risk.
6. Which assessment finding is the most sensitive indicator of early
postoperative hypovolemic shock?
A. Decreased blood pressure
B. Reduced urine output
C. Increased heart rate
D. Cold, clammy skin
Answer: C
Rationale: Tachycardia is often the earliest compensatory sign of hypovolemic shock as
the heart attempts to maintain cardiac output despite decreased volume.
7. The nurse observes a yellow, stringy substance in the base of a pressure
injury. What is the correct term for this tissue?
A. Slough
B. Granulation
C. Eschar
D. Exudate
Answer: A
Rationale: Slough is necrotic tissue that is typically yellow, tan, gray, green, or brown and
is stringy or adherent to the wound bed.
8. For a wound that is heavily draining (high exudate), which dressing type is
most appropriate?
A. Alginate
B. Hydrocolloid
C. Transparent film
D. Hydrogel
Answer: A
2026 |WCU
1. A patient’s surgical incision has pulled apart, and the nurse observes that
internal organs are protruding through the opening. Which is the immediate
priority action?
A. Apply a dry sterile dressing and call the surgeon
B. Place the patient in high-Fowler’s position
C. Push the organs back into the abdominal cavity gently
D. Cover the protruding organs with sterile gauze moistened with sterile normal saline
Answer: D
Rationale: Evisceration is a medical emergency. The nurse must cover the organs with
sterile saline-soaked gauze to prevent drying and infection, then notify the surgeon
immediately. The patient should be kept in low-Fowler’s with knees bent.
2. When assessing a pressure injury, the nurse notes full-thickness tissue loss
with visible subcutaneous fat, but bone, tendon, and muscle are not exposed.
How should this be staged?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: B
Rationale: Stage 3 involves full-thickness skin loss involving damage to or necrosis of
subcutaneous tissue that may extend down to, but not through, underlying fascia. Bone,
tendon, and muscle are not visible at this stage.
,3. The nurse is caring for a postoperative patient who has not voided for 8
hours. What is the most appropriate first action?
A. Perform a bladder scan
B. Increase the IV fluid rate
C. Insert a straight catheter immediately
D. Encourage the patient to drink more water
Answer: A
Rationale: A bladder scan is a non-invasive way to assess the volume of urine in the
bladder and confirm urinary retention before proceeding to invasive measures like
catheterization.
4. Which type of wound healing occurs when a surgical incision is closed with
sutures or staples?
A. Primary intention
B. Secondary intention
C. Tertiary intention
D. Granulation
Answer: A
Rationale: Primary intention healing occurs in wounds with minimal tissue loss and well-
approximated edges, such as clean surgical incisions.
5. A nurse is using the Braden Scale to assess a patient’s risk for pressure
injuries. A total score of 12 indicates which risk level?
A. No risk
B. Mild risk
C. Moderate risk
D. High risk
Answer: D
, Rationale: On the Braden Scale, a score of 12 or less generally indicates high risk (10-12 =
high risk, <9 = very high risk). Lower scores indicate higher risk.
6. Which assessment finding is the most sensitive indicator of early
postoperative hypovolemic shock?
A. Decreased blood pressure
B. Reduced urine output
C. Increased heart rate
D. Cold, clammy skin
Answer: C
Rationale: Tachycardia is often the earliest compensatory sign of hypovolemic shock as
the heart attempts to maintain cardiac output despite decreased volume.
7. The nurse observes a yellow, stringy substance in the base of a pressure
injury. What is the correct term for this tissue?
A. Slough
B. Granulation
C. Eschar
D. Exudate
Answer: A
Rationale: Slough is necrotic tissue that is typically yellow, tan, gray, green, or brown and
is stringy or adherent to the wound bed.
8. For a wound that is heavily draining (high exudate), which dressing type is
most appropriate?
A. Alginate
B. Hydrocolloid
C. Transparent film
D. Hydrogel
Answer: A
