Chapter 26. Wound Care
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. When reassessing a patient’s wound, a nurse notes redness and swelling, but no drainage. This is indicative of
a phase of healing called the
1. Reconstruction phase.
2. Remodeling phase.
3. Inflammatory phase.
4. Maturation phase.
2. A nurse is providing care for a patient who has just had surgery. The nurse understands that the
patient’s wound will need to be closely monitored for infection because it falls under the classification
of
1. Open wounds.
2. Closed wounds.
3. Contusion wounds.
4. Laceration wounds.
3. When assessing a patient’s wound, a nurse suspects that the wound most likely has been infected with
Clostridia because
1. A crackling sensation can be felt when palpating around the wound.
2. The area surrounding the wound is bright red and draining serosanguineous material.
3. The drainage from the wound has changed from serous to purulent.
4. The wound is not as well approximated as it appeared to be yesterday.
4. When irrigating a patient’s wound with a syringe, a nurse directs the flow of solution from the superior area
to the inferior area of the wound. The rationale for this action is to
1. Slow the irrigation of the wound, thus eliminating patient discomfort.
2. Assist the nurse in proceeding in an organized manner.
3. Direct the flow of solution from the least contaminated area to the most contaminated area.
4. Use gravity in increasing the force of the irrigation.
5. During an initial assessment, a nurse finds that a patient’s bone is visible in the pressure ulcer. The
nurse notifies the physician that the pressure ulcer appears to be at stage
1. I.
2. II.
3. III.
4. IV.
6. A patient’s wound, which has a slight amount of drainage, will benefit from a dressing that provides a
moist environment. Which type of dressing will the nurse apply?
1. Hydrofiber
2. Hydrocolloid
3. Gauze
4. Abdominal dressing pads (ABD)
7. A patient’s wound is showing signs of delayed healing. A nurse determines that the patient’s diet may be
the culprit and instructs the patient to eat more
1. Protein.
2. Vitamin B.
3. Vitamin D.
, 4. Fiber.
8. A nurse checks a patient’s Jackson-Pratt (JP) drain following surgery. The nurse explains to the patient that
a closed drain speeds healing and facilitates wound drainage by
1. Gravity.
2. Absorption.
3. Penetration.
4. Suction.
9. While assessing a patient’s surgical incision, a nurse notes that it is dry, clean, and intact, with
edges approximated. The incision is healing by
1. First intention.
2. Second intention.
3. Third intention.
4. Tertiary intention.
10. A patient who was involved in a motor vehicle accident is admitted to the hospital. The patient was thrown
from the vehicle, and the nurse finds several areas where the patient’s skin appears to have been scraped
away, most likely as a result of hitting the pavement. These types of injuries are termed
1. Lacerations.
2. Contusions.
3. Punctures.
4. Abrasions.
11. A nurse notes an increase in serosanguineous drainage from a patient’s incision. The most appropriate
action for the nurse to take is to
1. Notify the physician of increasing amounts of clear drainage.
2. Draw a circle around the drainage and write the date, time, and initials on the dressing.
3. Change the dressing to decrease the patient’s risk for infection.
4. Immediately call the laboratory and order a white blood cell (WBC) count.
12. A nurse charts that a patient has a contusion that is approximately 3 inches in diameter on the right thigh. The
nurse understands that a contusion is
1. A scrape or a scratch.
2. A discoloration of the skin.
3. An object embedded in the skin.
4. A cut or tear in the skin.
13. In explaining to a patient who is being dismissed from the hospital that he has a clean-contaminated wound,
the nurse states:
1. “Although the wound is an incision, it was grossly contaminated during surgery, so it
is important to notify your physician if the drainage increases.”
2. “Your incision seems to be developing a purulent drainage. Make sure that you notify
your doctor if you notice that the drainage develops a foul smell.”
3. “Your drainage cultured a high number of microorganisms, but since we’ve seen no
evidence of infection and you are taking an antibiotic, you probably don’t need to
worry
about it.”
4. “Surgical wounds are exposed to normal flora that resides on the skin. It is important
to observe it for signs of infection, such as drainage that turns yellow or green.”
14. A quadriplegic patient who was admitted for pneumonia was found to have a stage III pressure ulcer. A nurse
explains to the patient’s mother that she will know that the pressure ulcer is in the reconstruction phase of
healing when
, 1. A scab has formed over the wound.
2. Pink or red tissue can be seen in the wound.
3. The wound becomes warm to the touch.
4. A healing ridge has developed beneath the wound.
15. A nurse determines that the best way to clean a long incision that is sutured or stapled closed with
approximated edges is to
1. Use antiseptic swabs and clean from the inferior end of the incision to the superior end.
2. Use antiseptic swabs and clean around the wound in a circular manner.
3. Use sterile antiseptic swabs or cotton balls and forceps, and clean from the superior end
of the incision to the inferior end.
4. Use one cotton ball to make a circular sweep and then dispose of the cotton ball.
16. During a morning assessment, a nurse notices a change in a patient’s wound. Which of the following samples
of documentation would indicate a possible infection?
1. “Dressing dry and intact, small amount of serosanguineous drainage.”
2. “Incision line well-approximated, moderate amount of drainage noted.”
3. “Incision intact, small amount of pink granulation along incision line, no drainage.”
4. “Incision intact, moderate amount of purulent drainage, foul odor.”
17. The first step that a nurse must take to contribute to the development of a care plan for a patient with a
pressure ulcer is to
1. Determine the location of the ulcer.
2. Measure the length of the ulcer.
3. Gather all of the available data.
4. Assess the color of the drainage.
18. Upon answering a patient’s call light, a nurse finds that the patient’s wound has eviscerated. The nurse’s first
action is to
1. Prepare to do a dressing change with sterile Kerlix gauze.
2. Call the physician and collect sterile towels and saline.
3. Cover the wound with sterile dressings soaked in saline.
4. Obtain samples of purulent drainage and send them to the laboratory.
19. After assessing a patient with a stage II pressure ulcer, a nurse verifies that the patient is on a diet that will
enhance healing. This patient’s diet is
1. High carbohydrate, low calorie.
2. High protein, high calorie.
3. Low protein, high calorie.
4. Low carbohydrate, high calorie.
20. Prevention of a wound infection requires diligent care from a nurse. The first and most important step for the
nurse to take when emptying the patient’s Jackson-Pratt drain is to
1. Don sterile gloves.
2. Wash his or her hands.
3. Wipe the drain spout with alcohol.
4. Assess the contents of the drain.
21. A patient has wet-to-damp dressings ordered for a wound. A nurse will
1. Apply the dressings twice a day.
2. Moisten the dressings with sterile water.
3. Change the dressings frequently to prevent drying out.
4. Apply the dressings using clean technique.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. When reassessing a patient’s wound, a nurse notes redness and swelling, but no drainage. This is indicative of
a phase of healing called the
1. Reconstruction phase.
2. Remodeling phase.
3. Inflammatory phase.
4. Maturation phase.
2. A nurse is providing care for a patient who has just had surgery. The nurse understands that the
patient’s wound will need to be closely monitored for infection because it falls under the classification
of
1. Open wounds.
2. Closed wounds.
3. Contusion wounds.
4. Laceration wounds.
3. When assessing a patient’s wound, a nurse suspects that the wound most likely has been infected with
Clostridia because
1. A crackling sensation can be felt when palpating around the wound.
2. The area surrounding the wound is bright red and draining serosanguineous material.
3. The drainage from the wound has changed from serous to purulent.
4. The wound is not as well approximated as it appeared to be yesterday.
4. When irrigating a patient’s wound with a syringe, a nurse directs the flow of solution from the superior area
to the inferior area of the wound. The rationale for this action is to
1. Slow the irrigation of the wound, thus eliminating patient discomfort.
2. Assist the nurse in proceeding in an organized manner.
3. Direct the flow of solution from the least contaminated area to the most contaminated area.
4. Use gravity in increasing the force of the irrigation.
5. During an initial assessment, a nurse finds that a patient’s bone is visible in the pressure ulcer. The
nurse notifies the physician that the pressure ulcer appears to be at stage
1. I.
2. II.
3. III.
4. IV.
6. A patient’s wound, which has a slight amount of drainage, will benefit from a dressing that provides a
moist environment. Which type of dressing will the nurse apply?
1. Hydrofiber
2. Hydrocolloid
3. Gauze
4. Abdominal dressing pads (ABD)
7. A patient’s wound is showing signs of delayed healing. A nurse determines that the patient’s diet may be
the culprit and instructs the patient to eat more
1. Protein.
2. Vitamin B.
3. Vitamin D.
, 4. Fiber.
8. A nurse checks a patient’s Jackson-Pratt (JP) drain following surgery. The nurse explains to the patient that
a closed drain speeds healing and facilitates wound drainage by
1. Gravity.
2. Absorption.
3. Penetration.
4. Suction.
9. While assessing a patient’s surgical incision, a nurse notes that it is dry, clean, and intact, with
edges approximated. The incision is healing by
1. First intention.
2. Second intention.
3. Third intention.
4. Tertiary intention.
10. A patient who was involved in a motor vehicle accident is admitted to the hospital. The patient was thrown
from the vehicle, and the nurse finds several areas where the patient’s skin appears to have been scraped
away, most likely as a result of hitting the pavement. These types of injuries are termed
1. Lacerations.
2. Contusions.
3. Punctures.
4. Abrasions.
11. A nurse notes an increase in serosanguineous drainage from a patient’s incision. The most appropriate
action for the nurse to take is to
1. Notify the physician of increasing amounts of clear drainage.
2. Draw a circle around the drainage and write the date, time, and initials on the dressing.
3. Change the dressing to decrease the patient’s risk for infection.
4. Immediately call the laboratory and order a white blood cell (WBC) count.
12. A nurse charts that a patient has a contusion that is approximately 3 inches in diameter on the right thigh. The
nurse understands that a contusion is
1. A scrape or a scratch.
2. A discoloration of the skin.
3. An object embedded in the skin.
4. A cut or tear in the skin.
13. In explaining to a patient who is being dismissed from the hospital that he has a clean-contaminated wound,
the nurse states:
1. “Although the wound is an incision, it was grossly contaminated during surgery, so it
is important to notify your physician if the drainage increases.”
2. “Your incision seems to be developing a purulent drainage. Make sure that you notify
your doctor if you notice that the drainage develops a foul smell.”
3. “Your drainage cultured a high number of microorganisms, but since we’ve seen no
evidence of infection and you are taking an antibiotic, you probably don’t need to
worry
about it.”
4. “Surgical wounds are exposed to normal flora that resides on the skin. It is important
to observe it for signs of infection, such as drainage that turns yellow or green.”
14. A quadriplegic patient who was admitted for pneumonia was found to have a stage III pressure ulcer. A nurse
explains to the patient’s mother that she will know that the pressure ulcer is in the reconstruction phase of
healing when
, 1. A scab has formed over the wound.
2. Pink or red tissue can be seen in the wound.
3. The wound becomes warm to the touch.
4. A healing ridge has developed beneath the wound.
15. A nurse determines that the best way to clean a long incision that is sutured or stapled closed with
approximated edges is to
1. Use antiseptic swabs and clean from the inferior end of the incision to the superior end.
2. Use antiseptic swabs and clean around the wound in a circular manner.
3. Use sterile antiseptic swabs or cotton balls and forceps, and clean from the superior end
of the incision to the inferior end.
4. Use one cotton ball to make a circular sweep and then dispose of the cotton ball.
16. During a morning assessment, a nurse notices a change in a patient’s wound. Which of the following samples
of documentation would indicate a possible infection?
1. “Dressing dry and intact, small amount of serosanguineous drainage.”
2. “Incision line well-approximated, moderate amount of drainage noted.”
3. “Incision intact, small amount of pink granulation along incision line, no drainage.”
4. “Incision intact, moderate amount of purulent drainage, foul odor.”
17. The first step that a nurse must take to contribute to the development of a care plan for a patient with a
pressure ulcer is to
1. Determine the location of the ulcer.
2. Measure the length of the ulcer.
3. Gather all of the available data.
4. Assess the color of the drainage.
18. Upon answering a patient’s call light, a nurse finds that the patient’s wound has eviscerated. The nurse’s first
action is to
1. Prepare to do a dressing change with sterile Kerlix gauze.
2. Call the physician and collect sterile towels and saline.
3. Cover the wound with sterile dressings soaked in saline.
4. Obtain samples of purulent drainage and send them to the laboratory.
19. After assessing a patient with a stage II pressure ulcer, a nurse verifies that the patient is on a diet that will
enhance healing. This patient’s diet is
1. High carbohydrate, low calorie.
2. High protein, high calorie.
3. Low protein, high calorie.
4. Low carbohydrate, high calorie.
20. Prevention of a wound infection requires diligent care from a nurse. The first and most important step for the
nurse to take when emptying the patient’s Jackson-Pratt drain is to
1. Don sterile gloves.
2. Wash his or her hands.
3. Wipe the drain spout with alcohol.
4. Assess the contents of the drain.
21. A patient has wet-to-damp dressings ordered for a wound. A nurse will
1. Apply the dressings twice a day.
2. Moisten the dressings with sterile water.
3. Change the dressings frequently to prevent drying out.
4. Apply the dressings using clean technique.
