Nclexpn Quiz: Wound Care And Dressing Changes

20 questions · exam conditions

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Wound Care And Dressing ChangesQuestion 1 of 20

A nurse is caring for a 54-year-old client who is two days postoperative following an open cholecystectomy. During the morning assessment, the nurse notes that the abdominal dressing is saturated with a large amount of bright red drainage. The client's baseline vitals were stable, but the current heart rate has increased to 110 beats per minute.

Which action should the nurse take first?

Remove the current dressing to inspect the incision line.

Reinforce the dressing with additional sterile gauze pads.

Notify the primary health care provider immediately.

Perform a focused assessment of the client's blood pressure.

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Nclexpn Quiz

Nclexpn Quiz: Wound Care And Dressing Changes

Practice Wound Care And Dressing Changes in Nclexpn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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This quiz focuses on Wound Care And Dressing Changes, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexpn.

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Question 1

Which action should the nurse take first?

Remove the current dressing to inspect the incision line.
Reinforce the dressing with additional sterile gauze pads.
Notify the primary health care provider immediately.
Perform a focused assessment of the client's blood pressure. (correct answer)

Explanation: The presence of bright red (sanguineous) drainage saturating the dressing combined with tachycardia raises strong concern for postoperative hemorrhage. However, the LPN/VN's role is to collect complete focused data before reporting, because the blood pressure is the critical missing piece of the hemodynamic picture. A BP of 90/50 versus 130/80 fundamentally changes the urgency of the situation and the type of response the PHCP will need to order. Notifying without this information (C) provides an incomplete clinical report and could delay appropriate intervention. Checking BP takes approximately 60 seconds and ensures the report to the PHCP is accurate and actionable. Removing the dressing (A) is not the priority and could disrupt any clot that has begun to form. Reinforcing the dressing (B) may be appropriate simultaneously but is not the first data collection step.

Question 2

A nurse is caring for a client with a Jackson-Pratt (JP) drain following a mastectomy. The nurse notes that the drainage bulb is expanded and contains 40 mL of serosanguineous fluid.

Which action should the nurse take to ensure the drain continues to function properly?

Empty the bulb and then compress it fully before replacing the plug. (correct answer)
Keep the bulb in an upright position above the level of the incision.
Irrigate the tubing with 10 mL of sterile normal saline.
Secure the drain tubing to the client's bedsheet using a safety pin.

Explanation: A Jackson-Pratt drain is a closed-suction drainage device that functions by creating negative pressure through a compressed bulb. When the bulb expands, it indicates the suction has been lost and drainage is no longer being actively evacuated from the wound. The nurse must empty the bulb of its contents, then fully compress the bulb before reinserting the plug — this restores the negative pressure that draws fluid away from the surgical site. Keeping the bulb above the incision level (B) is incorrect; the drain should be positioned below the wound to assist gravity drainage in addition to suction. Irrigating the tubing (C) is not a standard maintenance action for JP drains and could introduce pathogens. Securing the tubing with a safety pin through the bedsheet (D) risks puncturing the drain tubing or creating a kink that obstructs drainage.

Question 3

The nurse is performing a sterile dressing change for a client with a mid-sternal surgical incision. The nurse is preparing to clean the incision site using sterile normal saline.

Which technique should the nurse use to clean the wound correctly?

Clean from the bottom of the incision upward toward the neck.
Wipe from the center of the incision toward the outer edges. (correct answer)
Use a back-and-forth scrubbing motion over the entire incision.
Use the same gauze pad to clean both the top and bottom of the wound.

Explanation: Wound cleaning follows the principle of moving from the least contaminated area to the most contaminated area — from clean to dirty. The incision line itself is the least contaminated area, and the surrounding skin harbors more microorganisms. Each stroke should move outward from the incision center using a single, smooth wipe, and a new gauze is used for each stroke. Cleaning from the bottom upward (A) may introduce bacteria from the surrounding skin over cleaned areas already addressed; direction along the incision line should also progress from clean to dirty. A scrubbing back-and-forth motion (C) recontaminates already-cleaned areas by dragging the same gauze over multiple surfaces. Using one gauze pad to clean both the top and bottom of the wound (D) transfers bacteria picked up in one area to another — each section of the wound requires a fresh gauze.

Question 4

While the nurse is assisting a client to ambulate on the first day after abdominal surgery, the client suddenly coughs and states, 'I felt something pop in my stomach.' The nurse observes that the surgical incision has opened and a loop of bowel is protruding.

Which action should the nurse take immediately?

Attempt to gently push the protruding bowel back into the abdomen.
Cover the protruding organ with sterile gauze soaked in sterile normal saline. (correct answer)
Place the client in a high-Fowler's position to improve breathing.
Instruct the client to take deep breaths and cough to clear their airway.

Explanation: Wound evisceration — protrusion of abdominal contents through an open incision — is a surgical emergency. The immediate nursing action is to cover the exposed bowel with sterile gauze that has been moistened with sterile normal saline. This prevents the exposed tissue from drying out (which causes rapid tissue death) and reduces the risk of contamination while emergency surgical intervention is arranged. The nurse should then call for help, remain with the client, and keep them calm. The client should be positioned supine with knees slightly flexed to reduce intraabdominal tension — not in high-Fowler's position (C), which would increase tension on the open wound. Attempting to push the bowel back (A) is strictly contraindicated as it risks bowel injury, vascular compromise, and introducing contamination into the peritoneal cavity. Instructing coughing (D) is also contraindicated because it increases intraabdominal pressure and can worsen the evisceration.

Question 5

Client: 82-year-old female, history of a recent stroke with residual left-sided paralysis. Admission Status: Admitted from home with a stage 3 pressure injury on the sacrum. 0800 Assessment: Wound measures 4 cm x 3 cm x 1 cm deep. The wound bed is 70% red (granulation tissue) and 30% yellow (slough). There is a moderate amount of foul-smelling, yellowish-green drainage. History: Urinary incontinence, poor nutritional intake, and limited mobility.

Which assessment finding is the most critical indicator of a localized wound infection?

The measurement of 4 cm x 3 cm.
The presence of red granulation tissue.
The foul-smelling, yellowish-green drainage. (correct answer)
The client's history of left-sided paralysis.

Explanation: Foul-smelling, yellowish-green (purulent) drainage is the most specific and critical clinical cue for a localized wound infection. Purulent drainage is composed of dead white blood cells, bacteria, and cellular debris — a direct indicator of an active infectious process. The combination of foul odor and purulence significantly raises concern for bacterial colonization beyond normal wound flora. Wound measurements (A) describe size but do not indicate infection. Red granulation tissue (B) is a sign of healthy wound healing — the presence of robust granulation indicates adequate vascularization and active repair. Left-sided paralysis (D) is a risk factor for pressure injury development and skin breakdown but is not an assessment finding from the current wound.

Question 6

The nurse recognizes that the client's risk for further skin breakdown is primarily increased by:

The foul odor of the current wound drainage.
The presence of slough in the wound bed.
The client's urinary incontinence and immobility. (correct answer)
The size of the current pressure injury.

Explanation: Urinary incontinence and immobility are the two primary modifiable risk factors driving further skin breakdown in this client. Incontinence exposes periwound and intact skin to prolonged moisture and the chemical irritants in urine, causing maceration and increasing susceptibility to breakdown. Immobility from the stroke and left-sided paralysis means pressure on bony prominences is constant and unrelieved, ischemia develops in compressed tissue, and repositioning cannot occur without assistance. Together, these factors represent the moisture-pressure combination that drives pressure injury development and progression. Foul odor (A) is a sign of infection in the existing wound, not a risk factor for new breakdown elsewhere. Slough (B) indicates devitalized tissue in the wound bed but does not directly increase the risk of new breakdown. Current wound size (D) does not predict risk for additional sites.

Question 7

Which intervention should the nurse include in the client's plan of care to promote wound healing?

Reposition the client at least every two hours. (correct answer)
Apply a dry, sterile dressing only when the client is asleep.
Limit the client's protein intake to reduce the workload on the kidneys.
Clean the wound with hydrogen peroxide twice daily.

Explanation: Repositioning the client at least every two hours is the foundational intervention for both preventing new pressure injuries and promoting healing of the existing one. Pressure relief restores circulation to ischemic tissue, delivers oxygen and nutrients to the wound bed, and removes the mechanical force that blocks healing. Applying a dry sterile dressing only at night (B) is inappropriate — dressing changes should follow a prescribed schedule regardless of the client's sleep state, and a dry dressing is not indicated for a stage 3 pressure injury requiring a moist healing environment. Limiting protein (C) is directly harmful; protein is essential for collagen synthesis, immune function, and tissue repair — this client's poor nutritional intake is a barrier to healing that should be addressed by increasing, not restricting, protein intake. Hydrogen peroxide (D) is cytotoxic to fibroblasts and granulation tissue — the very cells responsible for wound repair — and is explicitly contraindicated for wound bed care despite its historical use.

Question 8

The PHCP prescribes a wound culture and a hydrocolloid dressing. Which action should the nurse take when collecting the wound culture?

Collect the drainage directly from the old dressing.
Clean the wound with normal saline before swabbing the wound bed. (correct answer)
Swab only the yellow slough area to get the most bacteria.
Apply the new dressing before sending the culture to the lab.

Explanation: An accurate wound culture must sample the pathogens actually infecting the wound tissue — not surface contaminants, old exudate, or colonizing organisms on debris. Cleaning the wound with normal saline before swabbing removes surface contamination and ensures the culture reflects the true infecting organisms in the wound bed, producing results that can guide effective antibiotic therapy. Collecting drainage from the old dressing (A) yields organisms that have dried and mixed with environmental contaminants — this does not represent the current wound microenvironment. Swabbing slough specifically (C) is incorrect; slough is devitalized tissue that harbors surface colonizers, not necessarily the organisms causing deep tissue infection. The Levine technique (swab of the cleansed wound bed with slight pressure) is the preferred method. Applying the new dressing before the culture (D) would contaminate the swab and defeat the purpose of obtaining a clean sample.

Question 9

One week later, the nurse notes the wound measures 3 cm x 2 cm, the slough is gone, and there is no odor. The nurse determines the plan was successful because:

The client is consuming more of their meals.
The family expresses satisfaction with the care provided.
The client no longer requires pain medication.
The wound shows a decrease in size and absence of infection signs. (correct answer)

Explanation: The goals of wound management for this client were to reduce wound size, eliminate devitalized tissue (slough), and resolve infection. A decrease from 4x3 to 3x2 cm demonstrates wound contraction and healing. Absence of slough indicates the wound bed is now composed of healthy viable tissue. Resolution of odor confirms that the infectious process has been controlled. These are objective, measurable outcomes that directly evaluate the effectiveness of the wound care plan. Improved nutritional intake (A) is a positive and relevant finding that supports continued healing, but it measures a contributing factor rather than the wound outcome itself. Discontinuation of pain medication (C) may indicate improvement but can have many other explanations and is not a direct wound healing measure. Family satisfaction (B) is a valued outcome but is entirely subjective and does not confirm clinical effectiveness.

Question 10

A nurse is preparing to remove surgical staples from a client's healed abdominal incision as prescribed.

Which action should the nurse take during the procedure?

Pull the staple upward to stretch it before using the remover.
Remove all staples first, then clean the incision line with alcohol.
Squeeze the remover handles together to straighten the staple ends.
Place the lower tips of the staple remover under the center of the staple. (correct answer)

Explanation: The first and foundational step in staple removal is positioning: the lower tips of the staple remover are placed beneath the center bridge of the staple. Once correctly positioned, the handles are then squeezed, which bends the center of the staple upward and lifts the ends cleanly out of the skin without tearing tissue. Choice B describes this critical initial positioning step. Choice C describes the squeezing action that follows B; it is accurate as a subsequent step but not the first action to take during the procedure. Pulling the staple upward before using the remover (A) would apply direct force to the staple and cause unnecessary trauma to the surrounding tissue. Removing all staples first and then cleaning with alcohol (B) is incorrect on two counts: cleaning should occur before the procedure and between steps as needed, and alcohol is not the appropriate agent for a healing incision at this stage.

Question 11

A nurse is assessing a client with a large surgical wound.

Which clinical finding should the nurse identify as a systemic sign of infection rather than a localized sign?

Redness and warmth around the edges of the incision.
Thick, green drainage noted on the dressing.
The client's white blood cell count is 16,000 per cubic millimeter. (correct answer)
The client reports a "stabbing" pain at the wound site.

Explanation: An elevated white blood cell count (WBC of 16,000/mm3, above the normal range of 4,500-11,000) reflects leukocytosis — the body's systemic immune response to infection. When the immune system detects an infectious process, the bone marrow produces and releases additional white blood cells into the general circulation throughout the entire body. This is a systemic response, not confined to the wound site. In contrast, redness and warmth at the incision edges (A) represent localized vasodilation and increased blood flow limited to the wound area. Thick, green drainage (B) is localized purulence at the wound site. Wound pain (D) is the client's subjective experience of a localized inflammatory response. A systemic infection would also manifest as fever, tachycardia, and hypotension — classic signs of progressing sepsis.

Question 12

The nurse is assisting the PHCP with the removal of a Penrose drain from a client's surgical wound.

Which action should the nurse take during this procedure?

Provide the PHCP with sterile gloves and a sterile dressing kit. (correct answer)
Clamp the drain for two hours prior to the removal.
Instruct the client to perform the Valsalva maneuver during removal.
Cut the safety pin that is holding the drain in place.

Explanation: The nurse's primary role when assisting with an invasive or sterile procedure is to prepare and provide the necessary sterile supplies to maintain the sterile field and support the PHCP performing the procedure. This is within the LPN/VN scope of practice. Clamping the drain prior to removal (B) is not standard protocol for Penrose drain removal — Penrose drains are passive gravity drains without a mechanism that requires clamping before removal. The Valsalva maneuver (C) is indicated during central venous catheter removal to increase intrathoracic pressure and prevent air embolism — it is not indicated for Penrose drain removal, as there is no vascular access or air embolism risk. Cutting the safety pin (D) is incorrect and potentially dangerous; the safety pin (which prevents the drain from retracting into the wound) should be carefully removed intact, not cut, to avoid leaving fragments at the wound site.

Question 13

A nurse is caring for an older adult client admitted from a community-based setting. During the initial physical assessment, the nurse finds several stage 2 pressure injuries in different stages of healing and noted poor hygiene. The client's caregiver states, "They just spend all day in that one chair."

What is the nurse's priority legal responsibility in this situation?

Perform a sterile dressing change on all the pressure injuries.
Reinforce teaching with the caregiver on how to turn the client.
Follow the facility policy for reporting suspected neglect to authorities. (correct answer)
Document that the client's caregiver is not providing adequate care.

Explanation: Nurses are mandated reporters under law. When there is a reasonable suspicion of abuse, neglect, or exploitation of a vulnerable adult, the nurse has a legal obligation to report this to the appropriate authority according to facility policy and state law — this takes precedence over other nursing interventions in terms of legal responsibility. In this scenario, multiple pressure injuries in different stages of healing, combined with the caregiver's statement that the client sits in one chair all day and the finding of poor hygiene, constitutes reasonable suspicion of caregiver neglect. Performing dressing changes (A) is appropriate care but is not the priority legal responsibility. Caregiver education (B) may be relevant but assumes the situation is simply one of knowledge deficit rather than neglect — and cannot replace the mandated reporting obligation. Documentation of the caregiver's inadequacy in the client's chart (D) is part of the record-keeping process but does not fulfill the separate and distinct legal duty to report to authorities.

Question 14

Based on the current clinical data, which nursing hypothesis is the priority?

Impaired skin integrity related to pressure and moisture.
Risk for systemic infection related to the stage 3 pressure injury. (correct answer)
Imbalanced nutrition related to poor oral intake.
Acute pain related to the sacral wound.

Explanation: A stage 3 pressure injury with purulent, foul-smelling drainage in an immunocompromised elderly client carries a significant risk of progressing to osteomyelitis (bone infection, given the proximity to the sacrum) and sepsis if the infection extends systemically. Preventing systemic spread is the highest-priority safety hypothesis because it represents an immediately life-threatening potential consequence. Impaired skin integrity (A) is an accurate current-state hypothesis but describes the existing condition rather than its most dangerous potential consequence — it is subsumed within the infection risk concern. Imbalanced nutrition (C) is a significant factor affecting wound healing and requires intervention, but it is not the most immediately life-threatening hypothesis. Acute pain (D) warrants assessment but does not carry the same urgency as the risk of systemic infection.

Question 15

The nurse is reinforcing teaching with a client who is being discharged with a surgical wound that is healing by secondary intention. The nurse is explaining how to perform the prescribed wet-to-damp dressing changes at home.

Which instruction should the nurse include when reinforcing the information?

Pack the gauze tightly into the wound to ensure all surfaces are covered.
Make sure the moist gauze touches only the wound bed and not the surrounding skin. (correct answer)
Wait until the gauze is completely dry before removing it from the wound.
Clean the wound using a circular motion starting from the outside toward the center.

Explanation: In a wet-to-damp dressing, moistened gauze is placed only within the wound bed to maintain a moist healing environment. If the moisture contacts the periwound skin, it causes maceration — a softening and breakdown of intact skin from prolonged moisture exposure — which extends the area of tissue damage. The gauze should be gently placed in the wound without tightly packing (A), which could impair circulation and tissue perfusion within the wound. Waiting until the gauze is completely dry (C) describes the old wet-to-dry technique, which is now considered harmful because dry gauze adheres to granulation tissue and debrides healthy regenerating cells when removed. Cleaning in circular motions from outside toward center (D) reverses the correct technique, which always moves from clean (wound center) to contaminated (surrounding skin).

Question 16

A nurse is documenting the status of a client's surgical wound in the electronic health record.

Which entry provides the most complete and accurate description for the client's record?

"Wound looks good; dressing was changed as ordered by the doctor."
"Incision is 10 cm long, edges approximated, no drainage or redness noted." (correct answer)
"Small amount of drainage seen on the old bandage; client tolerated well."
"Wound is healing normally; will continue to monitor every shift."

Explanation: Accurate clinical documentation must be objective, specific, and measurable. Choice B provides a precise wound length (10 cm), a specific assessment of wound edge approximation, and clear negative findings (no drainage, no redness) — all of which would allow a subsequent nurse or provider to compare future assessments against an objective baseline. Choice A uses the subjective term 'looks good,' which conveys no objective clinical information and cannot be used for comparison or legal accountability. Choice C describes drainage vaguely ('small amount') without characterizing its color, consistency, or volume, and 'tolerated well' is a subjective phrase that is not clinically meaningful. Choice D uses the subjective phrase 'healing normally' and commits only to a monitoring schedule — it documents no findings at all. Professional documentation standards require specificity and objectivity to support continuity of care and legal accountability.

Question 17

A nurse is caring for a 4-year-old child with a small laceration on their knee that requires a dressing change. The child is crying and fearful of the procedure.

Which action should the nurse take to assist the child during the dressing change?

Allow the child to touch the clean gauze and help "pick out" the bandage. (correct answer)
Tell the child that "big kids" do not cry during nurse visits.
Perform the dressing change as quickly as possible without talking.
Ask the parents to leave the room so the child will behave better.

Explanation: For a preschool-age child (ages 3 to 5), developmentally appropriate care incorporates play, choice, and participation to reduce anxiety and build trust. Allowing the child to touch safe materials and choose the bandage gives them a sense of control over a frightening situation, which is the most effective approach for this developmental stage. Preschoolers are egocentric, think concretely, and fear bodily harm — fear during medical procedures is entirely normal and expected. Shaming the child for crying (B) is developmentally inappropriate and harmful to the therapeutic relationship; children this age are not capable of 'not crying' by choice. Performing the procedure silently and rapidly (C) increases anxiety by eliminating the child's ability to anticipate what is happening. Removing parents from the room (D) is counterproductive for a preschooler, whose anxiety is significantly reduced by the presence of trusted caregivers.

Question 18

The nurse is performing a dressing change for a client with a chronic venous stasis ulcer. The nurse notes the skin surrounding the wound is white, soft, and wrinkled.

The nurse should recognize this finding as:

Maceration from excessive moisture on the periwound skin. (correct answer)
A normal sign of healthy tissue regeneration.
An allergic reaction to the prescribed topical ointment.
Granulation tissue that is ready for a skin graft.

Explanation: White, soft, and wrinkled periwound skin is the classic presentation of maceration — tissue breakdown caused by prolonged exposure to moisture. In chronic wounds such as venous stasis ulcers, excess wound drainage, wound irrigation, or poorly chosen dressings that trap moisture can saturate the intact skin surrounding the wound. Macerated skin loses its structural integrity and is highly susceptible to further breakdown, which can expand the wound area. The goal of periwound skin care is to keep this area dry while maintaining moisture within the wound bed. A normal sign of tissue regeneration (B) describes granulation tissue, which appears as red, beefy, moist tissue within the wound bed — not the surrounding skin. Allergic contact dermatitis (C) typically presents as erythema, pruritus, and vesicles, not the blanched, soft, wrinkled appearance of maceration. Granulation tissue ready for grafting (D) is assessed within the wound bed itself, not the periwound skin.

Question 19

A nurse is caring for an immobilized client who is at high risk for skin breakdown.

Which intervention is a priority for the nurse to include in the client's plan of care?

Use a donut-shaped cushion when the client is sitting in a chair.
Massage red areas over the client's hips to improve circulation.
Keep the head of the bed elevated at 45 degrees at all times.
Apply a barrier cream to the client's bony prominences twice daily. (correct answer)

Explanation: Applying a barrier cream to bony prominences protects the skin from moisture damage — including perspiration and incontinence — and reduces friction, both of which contribute to skin breakdown in immobilized clients. Among the four choices, it is the only intervention that is clinically appropriate. Donut cushions (A) are specifically contraindicated for pressure injury prevention: they concentrate pressure around the periphery of the bony prominence, reduce circulation to the central tissue, and increase the risk of breakdown — the opposite of their intended effect. Keeping the head of the bed at 45 degrees (C) is also contraindicated; elevations greater than 30 degrees create shear forces on the sacral area as the client slides downward, significantly increasing pressure injury risk. Massaging reddened areas over bony prominences (B) is explicitly contraindicated — blanching or non-blanching redness indicates tissue that is already under pressure stress, and massage causes direct capillary trauma to already-compromised microcirculation, worsening ischemia rather than relieving it.

Question 20

The nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP) for a client with a wound drainage device.

Which task is appropriate for the nurse to delegate to the UAP?

Assess the skin around the drain site for redness or swelling.
Record the amount of drainage emptied from the collection container. (correct answer)
Reinforce the client's education on how to care for the drain at home.
Determine if the drainage amount is significantly less than the previous shift.

Explanation: Emptying a drain collection container and recording the output volume is a measurable, repetitive, data-collection task with a defined procedure that does not require clinical judgment — it falls within UAP scope. The nurse retains responsibility for interpreting the findings and taking action on them. Assessing the skin around the drain site (A) requires the clinical judgment to identify and interpret abnormal findings such as erythema, induration, or early infection — this is a nursing assessment function. Reinforcing discharge education (C) is a nursing responsibility requiring professional knowledge and the ability to evaluate learning. Determining whether the drainage amount is clinically significant compared to a prior shift (D) requires the nurse's clinical judgment to establish what constitutes a meaningful change — UAPs can report data but cannot make this evaluative determination.