BSN 205 SKILLS ISB QUIZZES EXPECTED QUESTIONS
WITH VERIFIED ANSWERS
Question 1.
When cleaning a wound during a dressing change, in what direction should the cleansing of the
wound take place? Outward from the wound in a circular motion. Towards the wound in a
circular motion. Clean around the wound edge only. Away from the wound in a linear pattern.
ANSWER
Correct Answer Outward from the wound in a circular motion.
Question 2.
What is a reason to use a wet to dry dressing? To keep the wound moist. To decrease healing
time. To debride a wound. To keep the wound from becoming infected.
ANSWER
Correct! To debride a wound. Wet-to-dry gauze dressings are mainly intended for use in wound
mechanical debridement and in this purpose they are conceptually distinct from wet-to-dry or
wet-to-moist gauze as a primary dressing in non-infected wounds
Question 3.
The wound vac dressing must be removed and replaced with a sterile dressing if the wound vac
is turned off for more than how many hours? 4 1 2 3
ANSWER
Correct! 2 If therapy is off for more than 2 hours, remove the old dressing and irrigate the wound.
Apply an alternative dressing at the direction of the treating clinician.
Question 4.
What is the most important dietary intake to promote pressure ulcer heal- Vitamin E Proteins
Calcium Carbohydrates
ANSWER
Correct! Proteins Increased protein levels have been linked to improved healing rates.
Question 5.
The report of a culture sent on a client's leg wound states "contaminated specimen." Which
nursing action most likely caused the outcome of this wound culture? Sample was collected
from the wound base Swab included pooled exudate. Inner ampule at the bottom of the tube
was crushed. Specimen tube cap was placed upside down on a firm dry surface.
ANSWER
Correct! Swab included pooled exudate. Pooled exudate is not cultured. These secretions contain a
mixture on contaminants that are not the same as those causing the infection. The sample sound be
collected from the base of the wound.
1
,Question 6.
A client wet-to-moist dressing for a leg wound. What technique should the nurse use when
changing this dressing? Tape the entire surface of the dressing. Apply fluffed gauze to the
wound bed and saturate with sterile normal saline. Press moistened fluffed gauze lightly into
wound depressions. Apply a clean dry 4 x 8 pad over the wet fluffed gauze
ANSWER
Correct! Press moistened fluffed gauze lightly into wound depressions. Moistened fluffed gauze
should be pressed lightly into the depressions in the wound.
Question 7.
A client has a hydrocolloid dressing over the right greater trochanter area. Which observation
indicates to the nurse that the dressing needs to be changed? Silk tape applied to window
frame the dressing Dressing located one third above the wound and two thirds below the wound
Presence of a white blister under the dressing Dressing changed 1 day ago
ANSWER
Correct! Presence of a white blister under the dressing The dressing should be changed if a white
blister appears under the dressing.
Question 8.
The nurse is caring for a client with a wound V.A.C. with black foam on the left heel. For what
should the nurse assess when changing the client's dressing? Amount of wound contraction
Boundary of shallow chronic ulcer Healing of superficial wound Improvement in tunneling
ANSWER
Correct! Amount of wound contraction Black foam has larger pores and is used to stimulate
granulation tissue and wound contraction, so this is what the nurse would assess.
Question 9.
A newly admitted client has a 3 cm x 5 cm reddened area over the coccyx. What should the
nurse do first for this client? Raise the head of the bed 45 degrees Massage the area. Clean the
area with hot water
ANSWER
Correct! Position the client off this area To prevent further skin damage, the client should be
positioned off the reddened area.
2
, Question 10.
The nurse prepares to change a client's sterile wound dressing. Which approach should the
nurse use if the old dressing is sticking to the site? Moisten the dressing with normal saline
Gently pull on the old dressing away from the wound. Gently pull on the old dressing toward the
wound. Pick the old dressing off with a pair of sterile forceps.
ANSWER
Correct! Moisten the dressing with normal saline If the older dressing adheres to the suture line, wet
it with sterile normal saline.
Question 11.
The nurse is measuring blood pressures as part of a community health fair. Which blood
pressure reading would cause the nurse to refer the patient for follow-up regarding
hypertension?
ANSWER
Correct! 138/88 A reading of 138/88 mm Hg has both systolic and diastolic pressures that are
considered high and classified as hypertension stage 1. This patient should be referred for additional
readings. The other readings are within normal limits, although all patients should be considered for
health promotion teaching regarding cardiac health, especially the patient with a blood pressure of
128/80 mm Hg, which is in the elevated category.
Question 12.
The nurse is admitting a stable patient for a minor outpatient procedure. What site would the
nurse most commonly use to assess pulse rate? Radial site Apical site Brachial site Carotid site
ANSWER
Correct Answer Radial site
Question 13.
The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature of
99.2° F (37.3° C) oral, pulse of 88 bpm and regular, respirations of 18 BPM and regular, blood
pressure of 178/112 mm Hg, and oxygen saturation of 96%. Which vital sign should the nurse
be most concerned about? Temperature Pulse Respirations Blood pressure
ANSWER
Correct! Blood pressure The blood pressure is well above the expected normal of less than 120/80
mm Hg and requires immediate follow-up evaluation by the nurse.
3
WITH VERIFIED ANSWERS
Question 1.
When cleaning a wound during a dressing change, in what direction should the cleansing of the
wound take place? Outward from the wound in a circular motion. Towards the wound in a
circular motion. Clean around the wound edge only. Away from the wound in a linear pattern.
ANSWER
Correct Answer Outward from the wound in a circular motion.
Question 2.
What is a reason to use a wet to dry dressing? To keep the wound moist. To decrease healing
time. To debride a wound. To keep the wound from becoming infected.
ANSWER
Correct! To debride a wound. Wet-to-dry gauze dressings are mainly intended for use in wound
mechanical debridement and in this purpose they are conceptually distinct from wet-to-dry or
wet-to-moist gauze as a primary dressing in non-infected wounds
Question 3.
The wound vac dressing must be removed and replaced with a sterile dressing if the wound vac
is turned off for more than how many hours? 4 1 2 3
ANSWER
Correct! 2 If therapy is off for more than 2 hours, remove the old dressing and irrigate the wound.
Apply an alternative dressing at the direction of the treating clinician.
Question 4.
What is the most important dietary intake to promote pressure ulcer heal- Vitamin E Proteins
Calcium Carbohydrates
ANSWER
Correct! Proteins Increased protein levels have been linked to improved healing rates.
Question 5.
The report of a culture sent on a client's leg wound states "contaminated specimen." Which
nursing action most likely caused the outcome of this wound culture? Sample was collected
from the wound base Swab included pooled exudate. Inner ampule at the bottom of the tube
was crushed. Specimen tube cap was placed upside down on a firm dry surface.
ANSWER
Correct! Swab included pooled exudate. Pooled exudate is not cultured. These secretions contain a
mixture on contaminants that are not the same as those causing the infection. The sample sound be
collected from the base of the wound.
1
,Question 6.
A client wet-to-moist dressing for a leg wound. What technique should the nurse use when
changing this dressing? Tape the entire surface of the dressing. Apply fluffed gauze to the
wound bed and saturate with sterile normal saline. Press moistened fluffed gauze lightly into
wound depressions. Apply a clean dry 4 x 8 pad over the wet fluffed gauze
ANSWER
Correct! Press moistened fluffed gauze lightly into wound depressions. Moistened fluffed gauze
should be pressed lightly into the depressions in the wound.
Question 7.
A client has a hydrocolloid dressing over the right greater trochanter area. Which observation
indicates to the nurse that the dressing needs to be changed? Silk tape applied to window
frame the dressing Dressing located one third above the wound and two thirds below the wound
Presence of a white blister under the dressing Dressing changed 1 day ago
ANSWER
Correct! Presence of a white blister under the dressing The dressing should be changed if a white
blister appears under the dressing.
Question 8.
The nurse is caring for a client with a wound V.A.C. with black foam on the left heel. For what
should the nurse assess when changing the client's dressing? Amount of wound contraction
Boundary of shallow chronic ulcer Healing of superficial wound Improvement in tunneling
ANSWER
Correct! Amount of wound contraction Black foam has larger pores and is used to stimulate
granulation tissue and wound contraction, so this is what the nurse would assess.
Question 9.
A newly admitted client has a 3 cm x 5 cm reddened area over the coccyx. What should the
nurse do first for this client? Raise the head of the bed 45 degrees Massage the area. Clean the
area with hot water
ANSWER
Correct! Position the client off this area To prevent further skin damage, the client should be
positioned off the reddened area.
2
, Question 10.
The nurse prepares to change a client's sterile wound dressing. Which approach should the
nurse use if the old dressing is sticking to the site? Moisten the dressing with normal saline
Gently pull on the old dressing away from the wound. Gently pull on the old dressing toward the
wound. Pick the old dressing off with a pair of sterile forceps.
ANSWER
Correct! Moisten the dressing with normal saline If the older dressing adheres to the suture line, wet
it with sterile normal saline.
Question 11.
The nurse is measuring blood pressures as part of a community health fair. Which blood
pressure reading would cause the nurse to refer the patient for follow-up regarding
hypertension?
ANSWER
Correct! 138/88 A reading of 138/88 mm Hg has both systolic and diastolic pressures that are
considered high and classified as hypertension stage 1. This patient should be referred for additional
readings. The other readings are within normal limits, although all patients should be considered for
health promotion teaching regarding cardiac health, especially the patient with a blood pressure of
128/80 mm Hg, which is in the elevated category.
Question 12.
The nurse is admitting a stable patient for a minor outpatient procedure. What site would the
nurse most commonly use to assess pulse rate? Radial site Apical site Brachial site Carotid site
ANSWER
Correct Answer Radial site
Question 13.
The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature of
99.2° F (37.3° C) oral, pulse of 88 bpm and regular, respirations of 18 BPM and regular, blood
pressure of 178/112 mm Hg, and oxygen saturation of 96%. Which vital sign should the nurse
be most concerned about? Temperature Pulse Respirations Blood pressure
ANSWER
Correct! Blood pressure The blood pressure is well above the expected normal of less than 120/80
mm Hg and requires immediate follow-up evaluation by the nurse.
3
