WOUND CARE EXAM QUESTIONS AND VERIFIED
ANSWERS
Question 1
What intervention to take for someone with low Braden Score
Correct Answer
score of <16 for hospitalized pt or <18 for older adult=high risk of
skin breakdown
TOPICAL SKIN CARE-keep skin clean, dry. apply moisture as needed,
assess daily
POSITIONING-reposition bed bound pt every 2-4 hrs if on pressure-
reducing mattress, every 1-2 hrs for regular mattress, or every hour if
in chair and can't reposiiton self every 15 min. if in lateral position
keep at 30 degree angle. keep HOB <30 degrees. keep heels off bed or
use heel protector.
SUPPORT SURFACES-maximize contact of body w/ surface of bed/chair
to redistribute wt over a lg area. reduces shear/friction/moisture. make
sure there's minimal layers of bed linens between pt and support
surface. STILL NEED TO REPOSITION PT! reevaluate often.
NUTRITION-fundemental for normal cell activity and tissue
repair/regeneration. do nutritional assessment, consult w/ RD if
necessary. req. adequate intake of PRO, FAT, and CHO. protein esp.
Page 1 of 322
,important b/c low PRO lvls cause hypoalbuminenia (causes
extracellular fluid shifts to tissues, increases edema, which changes
pressure in capillary circulation and interferes with O2 and nutrient
transportation. this increases pressure ulcer risk!)
Before performing a wound assessment, which nursing action would
reduce the patient's risk for infection?
A. Taking the patient's temperature
B. Applying clean gloves
C. Assessing the wound for drainage
D. Assessing the dressing for drainage
Correct Answer
B. Applying clean gloves
Question 2
Which wound would be allowed to heal by secondary intention?
A. Cleft lip repair
B. Infected hysterectomy incision
C. Exploratory laparoscopy incision
D. Facial laceration caused by a pocket knife
Correct Answer
B. Infected hysterectomy incision
Question 3
The nurse notes that a patient's surgical wound is healing slowly.
Which health problem would contribute to slow wound healing?
A. Osteoarthritis
B. Glaucoma
C. Deafness
D. Diabetes mellitus
Correct Answer
D. Diabetes mellitus
Question 4
Page 2 of 322
,Which intervention can the nurse delegate to nursing assistive
personnel (NAP) in caring for a patient with a wound?
A. Assessing the site for signs of redness or swelling
B. Reporting the presence of wound odor
C. Removing a soiled outer dressing
D. Opening sterile dressings during the dressing change
Correct Answer
B. Reporting the presence of wound odor
Question 5
A patient who had surgery yesterday has the initial dressing covering
the surgical site. What is the nurse's responsibility in assessing this
patient's wound?
A. Remove the dressing, inspect the wound, and reapply a new
dressing.
B. Inspect the wound and reapply the surgical dressing every 2 hours.
C. Inspect the wound, and keep the dressing off until the health care
provider arrives.
D. Wait until the health care provider orders the removal of the
surgical dressing.
Correct Answer
D. Wait until the health care provider orders the removal of the
surgical dressing
Question 6
Which action can the nurse delegate to nursing assistive personnel
(NAP) to help prevent the development of pressure ulcers in an older
adult patient?
A. Reposition the patient at least every 2 hours.
B. Assess the patient's bony prominences every shift.
C. Educate the family about the importance of healthy skin.
D. Assist the patient in the selection of high-protein foods.
Correct Answer
A. Reposition the patient at least every 2 hours.
Page 3 of 322
, Question 7
Which practice protects the nurse from infection when changing the
dressing on an infected pressure ulcer?
A. Begin antibiotic therapy before the dressing change.
B. Use appropriate personal protective equipment.
C. Adhere to sterile technique during the intervention.
D. Complete the dressing change in an effective, efficient manner.
Correct Answer
B. Use appropriate personal protective equipment.
Question 8
How would the nurse safely apply an enzyme debridement ointment?
A. Daub ointment on dead tissue at the wound edges.
B. Put ointment on a tongue blade, and gently spread it on the center
of the wound.
C. Apply ointment to necrotic tissue in the wound while avoiding
contact with surrounding skin.
D. Apply a gauze dressing to ensure contact with the ointment.
Correct Answer
C. Apply ointment to necrotic tissue in the wound while avoiding
contact with surrounding skin.
Question 9
The wound bed of a patient's pressure ulcer is red. What does this
finding indicate to the nurse?
A. Necrotic tissue
B. Presence of slough
C. Granulation tissue
D. Development of an infection
Correct Answer
C. Granulation tissue
Question 10
Page 4 of 322
ANSWERS
Question 1
What intervention to take for someone with low Braden Score
Correct Answer
score of <16 for hospitalized pt or <18 for older adult=high risk of
skin breakdown
TOPICAL SKIN CARE-keep skin clean, dry. apply moisture as needed,
assess daily
POSITIONING-reposition bed bound pt every 2-4 hrs if on pressure-
reducing mattress, every 1-2 hrs for regular mattress, or every hour if
in chair and can't reposiiton self every 15 min. if in lateral position
keep at 30 degree angle. keep HOB <30 degrees. keep heels off bed or
use heel protector.
SUPPORT SURFACES-maximize contact of body w/ surface of bed/chair
to redistribute wt over a lg area. reduces shear/friction/moisture. make
sure there's minimal layers of bed linens between pt and support
surface. STILL NEED TO REPOSITION PT! reevaluate often.
NUTRITION-fundemental for normal cell activity and tissue
repair/regeneration. do nutritional assessment, consult w/ RD if
necessary. req. adequate intake of PRO, FAT, and CHO. protein esp.
Page 1 of 322
,important b/c low PRO lvls cause hypoalbuminenia (causes
extracellular fluid shifts to tissues, increases edema, which changes
pressure in capillary circulation and interferes with O2 and nutrient
transportation. this increases pressure ulcer risk!)
Before performing a wound assessment, which nursing action would
reduce the patient's risk for infection?
A. Taking the patient's temperature
B. Applying clean gloves
C. Assessing the wound for drainage
D. Assessing the dressing for drainage
Correct Answer
B. Applying clean gloves
Question 2
Which wound would be allowed to heal by secondary intention?
A. Cleft lip repair
B. Infected hysterectomy incision
C. Exploratory laparoscopy incision
D. Facial laceration caused by a pocket knife
Correct Answer
B. Infected hysterectomy incision
Question 3
The nurse notes that a patient's surgical wound is healing slowly.
Which health problem would contribute to slow wound healing?
A. Osteoarthritis
B. Glaucoma
C. Deafness
D. Diabetes mellitus
Correct Answer
D. Diabetes mellitus
Question 4
Page 2 of 322
,Which intervention can the nurse delegate to nursing assistive
personnel (NAP) in caring for a patient with a wound?
A. Assessing the site for signs of redness or swelling
B. Reporting the presence of wound odor
C. Removing a soiled outer dressing
D. Opening sterile dressings during the dressing change
Correct Answer
B. Reporting the presence of wound odor
Question 5
A patient who had surgery yesterday has the initial dressing covering
the surgical site. What is the nurse's responsibility in assessing this
patient's wound?
A. Remove the dressing, inspect the wound, and reapply a new
dressing.
B. Inspect the wound and reapply the surgical dressing every 2 hours.
C. Inspect the wound, and keep the dressing off until the health care
provider arrives.
D. Wait until the health care provider orders the removal of the
surgical dressing.
Correct Answer
D. Wait until the health care provider orders the removal of the
surgical dressing
Question 6
Which action can the nurse delegate to nursing assistive personnel
(NAP) to help prevent the development of pressure ulcers in an older
adult patient?
A. Reposition the patient at least every 2 hours.
B. Assess the patient's bony prominences every shift.
C. Educate the family about the importance of healthy skin.
D. Assist the patient in the selection of high-protein foods.
Correct Answer
A. Reposition the patient at least every 2 hours.
Page 3 of 322
, Question 7
Which practice protects the nurse from infection when changing the
dressing on an infected pressure ulcer?
A. Begin antibiotic therapy before the dressing change.
B. Use appropriate personal protective equipment.
C. Adhere to sterile technique during the intervention.
D. Complete the dressing change in an effective, efficient manner.
Correct Answer
B. Use appropriate personal protective equipment.
Question 8
How would the nurse safely apply an enzyme debridement ointment?
A. Daub ointment on dead tissue at the wound edges.
B. Put ointment on a tongue blade, and gently spread it on the center
of the wound.
C. Apply ointment to necrotic tissue in the wound while avoiding
contact with surrounding skin.
D. Apply a gauze dressing to ensure contact with the ointment.
Correct Answer
C. Apply ointment to necrotic tissue in the wound while avoiding
contact with surrounding skin.
Question 9
The wound bed of a patient's pressure ulcer is red. What does this
finding indicate to the nurse?
A. Necrotic tissue
B. Presence of slough
C. Granulation tissue
D. Development of an infection
Correct Answer
C. Granulation tissue
Question 10
Page 4 of 322
