Sample Questions and Answers
Which of the following is the most appropriate method for assessing the severity of a burn wound?
A) Skin color
B) Blanching of the skin
C) Depth of the burn
D) Patient’s temperature
Answer: C) Depth of the burn
A nurse is caring for a patient with a pressure ulcer. Which of the following would be the most important to prevent further damage?
A) Apply a sterile dressing
B) Use a pressure-relieving device
C) Administer pain medications
D) Encourage increased fluid intake
Answer: B) Use a pressure-relieving device
Which of the following is the best method to prevent infection in a surgical wound?
A) Applying antibiotic ointment to the wound
B) Keeping the wound clean and dry
C) Restricting the patient’s movement
D) Massaging the wound daily
Answer: B) Keeping the wound clean and dry
The nurse is caring for a patient with a Stage II pressure ulcer. Which of the following interventions should the nurse include in the care plan?
A) Administer systemic antibiotics
B) Reposition the patient every 2 hours
C) Apply an occlusive dressing
D) Use a foam overlay on the bed
Answer: B) Reposition the patient every 2 hours
A patient with a wound has a significant amount of yellowish drainage. The nurse should document this as:
A) Serous
B) Sanguineous
C) Purulent
D) Serosanguineous
Answer: C) Purulent
A nurse is educating a patient on proper wound care. The nurse should teach the patient to:
A) Use cotton balls to clean the wound
B) Remove all scabs as soon as they form
C) Keep the wound moist to enhance healing
D) Apply heat to the wound to increase blood flow
Answer: C) Keep the wound moist to enhance healing
Which of the following is a risk factor for pressure ulcer development?
A) High body weight
B) Increased activity level
C) Immobility
D) Healthy skin
Answer: C) Immobility
Which stage of pressure ulcer is characterized by full-thickness tissue loss, exposing bone, tendon, or muscle?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
Answer: D) Stage IV
The nurse observes a patient’s surgical wound for signs of infection. Which of the following is the earliest sign of infection?
A) Fever
B) Increased pain
C) Redness and warmth
D) Increased drainage
Answer: C) Redness and warmth
A nurse is caring for a patient with a venous stasis ulcer. Which of the following interventions should be included in the patient’s care?
A) Elevate the legs above the level of the heart
B) Keep the legs in a dependent position
C) Use compression stockings with high pressure
D) Apply hot compresses to the legs
Answer: A) Elevate the legs above the level of the heart
A nurse is preparing to dress a patient’s wound. Which of the following is the priority action before applying a dressing?
A) Measure the wound size
B) Cleanse the wound with normal saline
C) Apply an antibiotic ointment
D) Check for signs of infection
Answer: B) Cleanse the wound with normal saline
The nurse is caring for a patient with a wound infection. What is the most common microorganism responsible for wound infections?
A) Streptococcus
B) Pseudomonas aeruginosa
C) Escherichia coli
D) Staphylococcus aureus
Answer: D) Staphylococcus aureus
A nurse is caring for a patient with a Stage III pressure ulcer. Which of the following interventions should be implemented?
A) Administer oral antibiotics
B) Use a hydrocolloid dressing
C) Apply a foam dressing
D) Reposition the patient every 4 hours
Answer: B) Use a hydrocolloid dressing
The nurse is assessing a burn patient. The skin appears red and painful, but intact. This is consistent with which degree of burn?
A) First-degree
B) Second-degree
C) Third-degree
D) Fourth-degree
Answer: A) First-degree
A patient has a wound that is healing by secondary intention. The nurse understands that this type of wound:
A) Requires sutures for closure
B) Is left open to heal from the inside out
C) Heals with minimal scarring
D) Heals with little or no drainage
Answer: B) Is left open to heal from the inside out
Which of the following dressing types is most appropriate for a wound with heavy exudate?
A) Gauze
B) Hydrocolloid
C) Alginate
D) Transparent film
Answer: C) Alginate
The nurse is assessing a patient with a burn injury. Which of the following should the nurse assess first?
A) Wound depth
B) Fluid balance
C) Pain level
D) Skin color
Answer: B) Fluid balance
A patient with a pressure ulcer is receiving nutritional therapy. The nurse understands that the goal is to:
A) Decrease fluid intake
B) Promote tissue repair
C) Decrease caloric intake
D) Increase wound drainage
Answer: B) Promote tissue repair
Which of the following is a characteristic of a Stage I pressure ulcer?
A) Full-thickness skin loss
B) Intact skin with non-blanchable redness
C) Shallow open ulcer
D) Skin loss involving muscle or bone
Answer: B) Intact skin with non-blanchable redness
A nurse is caring for a patient with a chronic wound. Which of the following is the most important factor for wound healing?
A) Adequate blood flow
B) Bed rest
C) Application of heat to the wound
D) Decreased protein intake
Answer: A) Adequate blood flow
A nurse is caring for a patient with a surgical wound. Which of the following is an expected outcome within the first 24 hours post-surgery?
A) Purulent drainage
B) Serosanguineous drainage
C) Yellow drainage
D) Thick, green drainage
Answer: B) Serosanguineous drainage
A nurse is preparing to perform a dressing change for a patient with a clean, post-operative wound. Which of the following is the nurse’s first priority?
A) Apply the new dressing
B) Assess the wound for signs of infection
C) Cleanse the wound with hydrogen peroxide
D) Obtain the patient’s consent for the procedure
Answer: B) Assess the wound for signs of infection
A nurse is caring for a patient with a wound infection. Which of the following should be monitored for potential complications?
A) Signs of dehiscence
B) Increased pain tolerance
C) Improved wound color
D) Decreased temperature
Answer: A) Signs of dehiscence
A patient with a pressure ulcer is on a special mattress. Which of the following should the nurse expect to occur?
A) Increased blood flow to the pressure points
B) Decreased pressure on the skin
C) Increased risk of infection
D) Skin dryness
Answer: B) Decreased pressure on the skin
The nurse is educating a patient on preventing pressure ulcers. Which of the following instructions should the nurse include?
A) Reposition every 4 hours
B) Avoid massaging bony prominences
C) Keep the skin dry and warm
D) Limit fluid intake
Answer: B) Avoid massaging bony prominences
The nurse is caring for a patient with a diabetic foot ulcer. Which of the following should be the priority action?
A) Administer pain medication
B) Elevate the foot
C) Assess for signs of infection
D) Apply a hydrocolloid dressing
Answer: C) Assess for signs of infection
A patient with a wound infection has a fever and increased drainage. Which of the following should the nurse do first?
A) Administer prescribed antibiotics
B) Obtain a wound culture
C) Change the dressing
D) Encourage fluid intake
Answer: B) Obtain a wound culture
The nurse is caring for a patient with a pressure ulcer. Which of the following is the most important aspect of wound care?
A) Removing the dressing every day
B) Maintaining a clean and moist environment
C) Using a hot compress to increase circulation
D) Applying ointments to the wound daily
Answer: B) Maintaining a clean and moist environment
A nurse is caring for a patient with a Stage II pressure ulcer. Which of the following dressings should be used?
A) Hydrocolloid dressing
B) Transparent film dressing
C) Wet-to-dry dressing
D) Dry gauze dressing
Answer: A) Hydrocolloid dressing
A nurse is teaching a patient how to care for a wound at home. Which of the following is the most important instruction?
A) Avoid touching the wound with bare hands
B) Keep the wound covered at all times
C) Change the dressing every 12 hours
D) Soak the wound in warm water daily
Answer: A) Avoid touching the wound with bare hands
31. A nurse is caring for a patient with a venous ulcer. The nurse knows that which of the following interventions is most effective for preventing further complications?
A) Keeping the legs elevated
B) Applying pressure bandages
C) Using heat therapy to promote circulation
D) Encouraging frequent ambulation
Answer: A) Keeping the legs elevated
32. The nurse is teaching a patient with a pressure ulcer about nutrition. The nurse should recommend which of the following to promote wound healing?
A) High-calorie, high-protein diet
B) Low-fat diet
C) High-carbohydrate diet
D) Low-sodium diet
Answer: A) High-calorie, high-protein diet
33. Which of the following interventions should the nurse implement to prevent pressure ulcers in an immobile patient?
A) Use a water mattress
B) Reposition the patient every 4 hours
C) Apply skin moisturizers daily
D) Encourage fluid intake to prevent dehydration
Answer: A) Use a water mattress
34. A nurse is preparing to apply a hydrocolloid dressing to a patient’s wound. Which of the following is a characteristic of hydrocolloid dressings?
A) They are non-occlusive
B) They promote a dry wound environment
C) They are used for highly exudative wounds
D) They require frequent dressing changes
Answer: B) They promote a dry wound environment
35. A patient is being discharged with instructions for caring for a wound at home. The nurse should instruct the patient to:
A) Avoid removing the scab to promote faster healing
B) Wash the wound with soap and water and then dry it thoroughly
C) Apply a fresh dressing only when the wound becomes infected
D) Apply heat to the wound to reduce inflammation
Answer: B) Wash the wound with soap and water and then dry it thoroughly
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