1. 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.
1a

d. Wait until the health care provider orders the removal of the surgical dressing.
1b

2. When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality? a. The drainage is odorless. b. The drainage is straw colored. c. The patient doesn't like looking at the drainage tubing. d. The amount of drainage was greater today than yesterday.
2a

d. The amount of drainage was greater today than yesterday.

2b

3. 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.
3a

a. Reposition the patient at least every 2 hours.

3b

4. 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.
4a

c. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
4b

5. When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? a. After performing hand hygiene at the start of the procedure b. Before removing the inner dressing c. After removing the original dressing materials and performing hand hygiene a second time d. Just before cleansing the wound with sterile water
5a

c. After removing the original dressing materials and performing hand hygiene a second time
5b

6. What is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago? a. Notify the surgeon of the bleeding. b. Remove the dressing, and assess the wound. c. Assess the patient for signs of shock. d. Further assess the patient and the wound.
6a

d. Further assess the patient and the wound.

6b

7. Which measurements would the nurse use to calculate the surface area of a patient's pressure ulcer? a. Height and weight b. Length and width c. Length and depth d. Width and depth

7a

b. Length and width

7b

8. What is the proper method for cleansing the evacuation port of a wound drainage system? a. Cleanse it with normal saline. b. Wash it with soap and warm water. c. Rinse it with sterile water. d. Wipe it with an alcohol sponge.

8a

d. Wipe it with an alcohol sponge.

8b

9. Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied? a. Pinning the tubing to the patient's hospital gown b. Compressing the bulb while replacing the port cap c. Emptying the drainage container only when it is 90% full d. Placing the drainage container below the wound site
9a

b. Compressing the bulb while replacing the port cap

9b

10. A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? a. Drainage that was not present previously b. Redness at the abdominal suture line c. Granulation tissue in the wound bed d. The patient reports less pain
10a

a. Drainage that was not present previously

10b

11. Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected? a. White blood cell count b. Complete blood count c. X-ray of left foot d. Culture and sensitivity test
11a

d. Culture and sensitivity test

11b

12. 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

12a

c. Granulation tissue

12b

13. 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

13a

b. Infected hysterectomy incision

13b

14. 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

14a

b. Applying clean gloves

14b

15. A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? a. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention. b. Use a distraction technique to divert the patient's attention during the procedure. c. Position the patient comfortably before the intervention. d. Thoroughly explain the procedure to the patient.
15a

a. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
15b

16. Which device is used for wound irrigation? a. 19-gauge needle attached to a 10-mL syringe b. 19-gauge needle attached to a 35-mL syringe c. Sterile container held 30.5 cm (12 inches) above the wound c. Foley irrigating syringe
16a

b. 19-gauge needle attached to a 35-mL syringe

16b

17. Which action should the nurse avoid before irrigating a patient's foot wound? a. Assess the patient for a history of allergies to tape and irrigating solution. b. Review the provider's orders for the type of irrigating solution to be used. c. Assess the patient's pain on a scale of 0 to 10. d. Warm the irrigant to body temperature in the microwave.
17a

d. Warm the irrigant to body temperature in the microwave.

17b

18. Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? a. Begin antibiotic therapy before the dressing change. b. Use appropriate personal protective equipment (PPE). c. Adhere to sterile technique during the intervention. d. Complete the dressing change in an effective, timely way.

18a

b. Use appropriate personal protective equipment (PPE).

18b

19. Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? a. Cleansing the wound with sterile water b. Blotting the incision with dry gauze c. Wearing sterile gloves to cleanse the wound d. Using a new gauze pad for each stroke while cleansing the wound
19a

d. Using a new gauze pad for each stroke while cleansing the wound
19b

20. Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site? a. Attach the tubing to the patient's gown with a safety pin. b. Tape the tubing to the patient's bed. c. Attach the tubing to the nearest side rail. d. Loop the tubing through the bed frame.
20a

a. Attach the tubing to the patient's gown with a safety pin.

20b

21. 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
21a

b. Reporting the presence of wound odor

21b

22. 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
22a

d. Diabetes mellitus

22b

23. 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.
23a

b. Use appropriate personal protective equipment.

23b

24. What is the nursing action to set up suction for a hemovac drainage system? a. Set the suction to lowest level possible. b. Hemovacs are always set to medium suction. c. Connect to the wall on intermediate suction. d. Compress the hemovac, creating suction.
24a

d. Compress the hemovac, creating suction.

24b

25. When irrigating a wound, how would the nurse know the right amount of pressure to apply? a. Calculate the wound size. b. Follow the general rule of keeping the pressure between 4 and 15 psi. c. Keep the pressure strong enough to cause moderate pain. d. Gentle enough that it does not create a splash off of the wound.
25a

b. Follow the general rule of keeping the pressure between 4 and 15 psi.
25b