Wound Care And Dressing Changes - NCLEX Pn

1. Which PPE is required when a wound dressing change may involve splashes or sprays?

   Gloves, gown, mask, and eye protection as indicated. Protects the nurse from exposure to blood or body fluids during procedures with potential for aerosolization.

2. Which intervention best prevents periwound skin breakdown from frequent drainage?

   Apply a skin barrier protectant to periwound skin. Creates a protective layer against maceration and irritation from excessive moisture or enzymes in drainage.

3. What is the priority assessment to document about wound drainage on the removed dressing?

   Amount, color, odor, and consistency of drainage. Provides essential data for evaluating wound healing progress and detecting signs of infection or complications.

4. What is the correct action if an old dressing adheres to the wound during removal?

   Moisten with sterile normal saline and remove gently. Prevents trauma to healing tissue while facilitating safe removal without disrupting the wound bed.

5. Which solution is commonly used for routine wound cleansing unless contraindicated?

   Sterile normal saline. Effectively removes debris and bacteria without causing irritation or toxicity to healing tissues.

6. What is the correct action if a sterile field becomes contaminated during a dressing change?

   Stop and replace contaminated items; re-establish sterility. Ensures the integrity of the aseptic environment to prevent wound contamination and infection.

7. What is the immediate nursing action if evisceration occurs?

   Cover with sterile saline-moistened dressings and notify provider. Maintains moisture and sterility while awaiting surgical intervention to prevent further protrusion or infection.

8. Which dressing type is most appropriate for heavy exudate due to high absorbency?

   Alginate dressing. Forms a gel with exudate to manage high drainage volumes and promote a moist healing environment.

9. What is tunneling in a wound assessment?

   A channel extending from the wound into deeper tissue. Creates pathways for infection spread and complicates healing by extending damage beyond the visible wound.

10. Which technique is typically appropriate for changing a chronic wound dressing in the home setting?

    Clean technique (unless agency or provider requires sterile). Balances infection control with practicality in non-acute settings where full sterility may not be necessary.

11. What is undermining in a wound assessment?

    Tissue destruction under intact skin along wound edges. Indicates hidden tissue damage that can lead to wound expansion and delayed healing if not addressed.

12. Which wound bed tissue is yellow or white and may indicate nonviable tissue or exudate?

    Slough. Consists of necrotic debris that can impede healing and may require debridement for progress.

13. Which wound bed tissue is described as red, moist, and bumpy and indicates healing?

    Granulation tissue. Represents new vascular tissue formation essential for wound closure and epithelialization.

14. What is the correct method to measure wound depth at the bedside?

    Insert a sterile cotton-tipped applicator and measure to skin level. Allows accurate assessment of wound extent for appropriate treatment planning and monitoring.

15. What is the correct action after completing a dressing change and removing gloves?

    Perform hand hygiene immediately after glove removal. Eliminates residual microorganisms from hands that may have been transferred during glove removal.

16. What patient position is appropriate when dehiscence or evisceration is suspected?

    Supine with knees flexed to reduce abdominal tension. Minimizes intra-abdominal pressure to prevent further separation or protrusion of organs.

17. Which direction should you cleanse a linear surgical incision with sterile gauze?

    From the incision outward (clean to less clean). Prevents dragging contaminants from surrounding skin into the clean incision area.

18. Which direction should you cleanse a circular wound (for example, around a stoma or pin site)?

    From the center outward in concentric circles. Minimizes spreading contaminants from the wound center to cleaner peripheral areas.

19. What does wound dehiscence mean?

    Partial or complete separation of wound edges. Results from failure of wound edges to adhere, often due to infection, tension, or poor nutrition.

20. Which wound bed tissue is black or brown and indicates devitalized tissue?

    Eschar. Forms a barrier that prevents healing and often requires removal to promote tissue regeneration.

21. Which technique is used to apply a sterile dressing to a surgical wound: sterile or clean?

    Sterile technique. Prevents introduction of microorganisms into the open surgical site to minimize infection risk.

22. Which dressing type provides cushioning and is often used for partial-thickness wounds with exudate?

    Foam dressing. Absorbs exudate while providing padding to protect the wound from trauma and contamination.

23. Which finding is most concerning for wound infection during assessment?

    Purulent drainage with increasing redness, warmth, and pain. Indicates bacterial invasion and inflammation, requiring prompt intervention to prevent systemic spread.

24. What is the correct hand hygiene step immediately before any wound dressing change?

    Perform hand hygiene before touching the patient or supplies. Reduces the risk of introducing pathogens to the wound site and maintains aseptic conditions during the procedure.

25. Which dressing type maintains a moist environment and is used for light-to-moderate exudate?

    Hydrocolloid dressing. Promotes autolytic debridement and protects the wound while absorbing moderate drainage.

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