Wound Care/Dressing Reviewer

1. A nurse is assessing a patient's skin and notes a 3 cm shallow crater on the buttocks.
The patient winces when palpated. How should the nurse stage this wound?

A. Stage 1 pressure ulcer ❌ – Stage 1: intact skin with non-blanchable redness.

B. Stage 2 pressure ulcer ✅ – Shallow open ulcer with red/pink wound bed, partial
thickness loss.

C. Stage 3 pressure ulcer ❌ – Full thickness skin loss, may involve subcutaneous
fat.

D. Stage 4 pressure ulcer ❌ – Exposed bone, tendon, or muscle.

2. Which of the following are functions of dressings? (Select all that apply)

A. Promote hemostasis ✅ – Dressings help control bleeding.

B. Keep wound bed dry ❌ – Moist wound healing is preferred; dryness delays
healing.

C. Wound debridement ✅ – Some dressings assist in removing dead tissue.

D. Prevent contamination ✅ – Dressings act as a barrier from bacteria and dirt.

E. Increase circulation ❌ – Dressings don’t directly increase circulation.

3. Which patients would benefit from moist-to-dry dressing (mechanical debridement)?

A. 24 y/o with open infected spider bite ✅ – Infected wounds may need
debridement.

B. 7 y/o with abrasions ❌ – Superficial wounds usually don’t require debridement.

C. 50 y/o post-op incision ❌ – Closed surgical incisions heal better with clean, dry
dressings.

D. 30 y/o with necrotic tissue crater ✅ – Necrotic wounds require mechanical

debridement.
4. Knee replacement surgery patient has redness, warmth, and increased pain
medication request. Concern?

A. Nothing expected❌ – Redness + warmth are not normal on day 5.

B. Medication dependence ❌ – The issue is wound-related, not addiction.

C. Wound dehiscence ❌ – No signs of separation mentioned.

D. Wound infection ✅ – Classic signs of infection: redness, warmth, pain.

5. Nurse Lee teaching about wound healing. Which is correct?

A. Inadequate nutrition delays healing ✅ – Poor protein/calorie intake delays repair.

B. Chronic wounds heal better dry ❌ – Moist environment promotes healing.
❌ – Fat heals slower due to poor vascularity.
C. Fat tissue heals faster

D. Steroids speed healing ❌ – Steroids delay healing by suppressing inflammation.

6. Risk factors for pressure ulcer development include:

A. Diet low in calories and fat ❌ – Malnutrition is a risk, but low protein is more
concerning.

B. Altered LOC ✅ – Decreased awareness → less repositioning → high risk.

C. Shortness of breath ❌ – Not a direct risk factor.

D. Muscular pain ❌ – Not a major factor.

7. Post-hysterectomy patient complication of wound healing:

A. Itching❌ – Normal in healing phase.

B. Approximated incision ❌ – Good sign, not complication.

C. Pain ❌ – Expected in healing.

D. Bluish mass on incision ✅ – May indicate hematoma, a complication.

8. Which finding suggests dehiscence?

A. 'Something gave way' ✅ – Classic symptom of wound separation.

B. Protrusion of organs ❌ – That’s evisceration.

C. Chronic drainage ❌ – Indicates infection/fistula, not dehiscence.

D. Purulent drainage ❌ – Infection, not dehiscence.

9. Patient with a black ulcer on left hip. Next step?

A. Monitor ❌ – Black = necrotic tissue, needs action.

B. Irrigate ❌ – Irrigation won’t remove necrosis.

C. Debridement ✅ – Dead tissue must be removed for healing.

D. Drainage management ❌ – Drainage is secondary; necrosis is primary issue.

10. Skin integrity assessment includes:

A. Pressure points ✅ – Nurses check for redness, breakdown, ulcers.

B. Pulses ❌ – Circulation assessment, not skin integrity.
C. Breath sounds ❌ – Respiratory assessment.

D. Bowel sounds ❌ – GI assessment.

11. Wound dehiscence initial management:

A. Cover with sterile saline-moistened towels ✅ – Prevents tissue drying & infection.
❌ – Not safe; surgeon needed.
B. Close with Steri-Strips

C. Pour hydrogen peroxide ❌ – Tissue-damaging.

D. Hold wound manually ❌ – Unsafe and ineffective.

12. To prevent pressure ulcers, turn patient every:

A. 2 hours ✅ – Standard guideline for immobile patients.

B. 3 hours ❌ – Too long; increases risk.

C. 4 hours ❌ – Risk of breakdown rises.

D. 2 minutes ❌ – Unnecessary.
13. Older adult with leg edema, redness, and clear drainage. Cause?

A. Beta-hemolytic streptococcus ❌ – Would cause infection with pus, not clear

drainage.

B. Age❌ – Not direct cause.

C. Venous insufficiency ✅ – Common in older adults → edema + stasis dermatitis.

D. Hemangioma ❌ – Benign vascular lesion, unrelated.

14. Removal of devitalized tissue in pressure ulcers is:

A. Irrigation ❌ – Rinses but doesn’t remove necrosis.

B. Sterile technique ❌ – Infection prevention, not removal.

C. Debridement ✅ – Process of removing necrotic tissue.

D. Exudates ❌ – Refers to wound drainage, not removal process.

15. Example of a closed wound:

A. Abrasion ❌ – Open wound.

B. Ecchymosis ✅ – Bruise = closed wound with bleeding under skin.

C. Incision ❌ – Open wound made by sharp object.

D. Puncture ❌ – Open wound caused by sharp object penetration.

16. The nurse is observing the patient's wife perform the damp-to-dry dressing change.
Which actions, if made by the patient's wife, indicate further instruction is needed?
(Select all that apply)

❌A. Pre-medicates for pain

✅B. Packs wound tightly
✅C. Leaves contact or primary dressing dripping moist
❌D. When removing the old dressing the wife leaves the dressing dry, even when it
sticks slightly.

❌E. Pulls tape in direction toward wound when removing previous dressing.
17. A patient with a wound vacuum-assisted closure (wound V.A.C) continues to
complain of pain. What measures may be taken? (Select all that apply)

✅A. Switch to the white polyvinyl alcohol (PVA) soft foam.

✅B. Decrease the pressure setting.
✅C. Administer pain medication.
❌D. Switch to the black polyurethane (PU) foam.
❌E. Keep the suction in the "off" position.
18. During a sterile dressing change, when are the gloves changed?

❌A. After the old dressing is removed and before creating a sterile field.
✅B. After the old dressing is removed and before cleansing the wound.
❌C. After the old dressing is removed, after cleansing the wound, and before applying a
new dressing.

❌D. It is unnecessary to change gloves for chronic wounds

19. A patient states that she is unable to get her transparent dressing to stay in place.
What instruction should the nurse provide the patient?

❌A. "If you are having difficulty with your dressing changes, we can see if the doctor
will give you a referral to a home care agency."

✅B. "Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75cm) around the
wound, and that the skin is thoroughly dry before applying the dressing."

❌C. "This type of dressing requires frequent changing because they do not stay in
place."

❌D. "You probably are applying it incorrectly, or perhaps you are just too anxious about
having to perform the dressing change."

❌E. "There are many options on the market. Why don't you try to use a non-adhesive-
backedtransparent dressing instead?"
20. A patient asks the nurse why the Montgomery ties are being used instead of regular
tape. What is the nurse's best response?

❌A. "Because Montgomery ties are nonallergenic."

❌B. "Montgomery ties can be tied tighter, providing a more secure dressing and greater
support of the wound."

❌C. "Montgomery ties allow the wound to breathe."

✅D. "Montgomery ties avoid frequent removal of tape, which is irritating to the skin
during dressing changes"

21. How can the nurse determine that negative pressure is being achieved with a wound
vac?

❌A. The nurse can inquire about the patient's pain level. If there is a reported decrease
in the level of pain, then the wound is constricting and negative pressure is being
achieved.

❌B. The nurse can ensure that there is no whistling noise at the wound site and that the
wound VAC has not triggered its alarm.

✅C. The nurse can check for air leaks by listening with a stethoscope or by moving the
hand around the edges of the wound while applying light pressure.

❌D. The nurse can ensure that the foam is in contact with the entire wound base,
margins, and tunneled and undermined areas.

22. Which of the following is a correct sequence for changing a gauze dressing.

✅A. Remove old dressing, discard gloves and perform hand hygiene, create sterile field,
apply sterile gloves, clean wound, blot dry, apply new dressing.

❌B. Remove old dressing, discard gloves, apply new gloves, and apply new dressing.
❌C. Remove old dressing, discard gloves, clean wound, apply loose woven gauze, and
cover with thicker woven pad (e.g., ABD pad).

❌D. Create sterile field, remove old dressing, discard gloves and perform hand hygiene,
apply new gloves, clean wound, blot dry, apply new dressing.