Question 1 of 10: Match The Potential Complication To The Symptoms

Question
1 of 10
Match the potential complication to the
symptoms.
Protrusion of visceral organs through a wound opening.
 Evisceration.
Abnormal passage between two organs, chronic drainage.

 Fistula.
Increased white blood cell count, fever, purulent drainage.

 Infection.
Hypotension, tachycardia, hematoma formation.

 Hemorrhage.
Partial or total separation of wound layers; patient states

that it feels like something has given way.
 Dehiscence.
Question 4 of 10
Which of the following patients has
the least risk for developing a wound
infection?
 A patient with peripheral vascular disease and an ulcer on the
heel.
The chances of wound infection are greater when the wound
contains dead or necrotic tissue (as with a burn), there are
foreign bodies in or near the wound, and the blood supply and
local tissue defenses are reduced or the patient is
immunocompromised.
 A patient receiving chemotherapy who has a surgical incision.
immunocompromised.
INCORRECT
 A 17-year-old patient who has a metal fragment lodged in his

thigh.
immunocompromised.
CORRECT
 A 30-year-old woman who had an episiotomy with childbirth.

immunocompromised.
 An 80-year-old man who has a burn.
immunocompromised.
Question 5 of 10
When teaching a patient about wound healing,
what should the nurse tell the patient?
 Fat tissue heals more readily because there is less
vascularization.
Inadequate nutrition—including proteins, carbohydrates, lipids,
vitamins, and minerals—delays tissue repair and increases risk
for infection. Both full-thickness wounds and partial-thickness
wounds heal more efficiently in a moist, protected environment.
Long-term steroid therapy may diminish the inflammatory
response and reduce the healing potential. Steroids slow
collagen synthesis. Fat tissue has less blood supply, which
decreases transport of nutrients and cellular elements required
for healing.
CORRECT
 Inadequate nutrition delays wound healing and increases risk

of infection.
for healing.
INCORRECT
 Chronic wounds heal more efficiently in a dry, open
environment, so leave them open to air when possible.
for healing.
 Long-term steroid therapy diminishes the inflammatory
response and speeds wound healing.
for healing.
Question 6 of 10
The nurse is caring for a patient who had knee
replacement surgery 5 days ago. The patient’s
knee appears red and is very warm to the
touch. The patient requests pain medication.
Which of the following would be a correct
explanation of what the nurse has assessed?
INCORRECT
 The nurse should observe the patient more closely for wound
dehiscence.
The risk for infection is greatest 4 to 5 days postoperative.
Symptoms of wound infection include fever, tenderness and pain
at the wound site, and an elevated white blood cell count, and
the edges of the wound may appear inflamed. If drainage is
present, it is odorous and purulent, which causes a yellow,
green, or brown color, depending on the causative organism.
CORRECT
 The patient is demonstrating signs of a postoperative wound

infection.
 These are expected findings for this postoperative period.
 The patient is becoming dependent on pain medication.
Question 7 of 10
The nurse is caring for a patient after major
abdominal surgery. Which of the following
demonstrates correct understanding of wound
dehiscence?
 Wound dehiscence is most likely to occur during the first 24 to
48 hours after surgery.
An increase in drainage is a symptom of a potential dehiscence.
Wound dehiscence most commonly occurs before collagen
formation (3 to 11 days after injury). To prevent dehiscence,
place a folded thin blanket or pillow over an abdominal wound
when the patient is coughing. This provides a splint to the area,
supporting the healing tissue when coughing increases the intra-
abdominal pressure. Evisceration is an emergency that requires
surgical repair. Dehiscence does not necessarily indicate surgery
is necessary.
CORRECT
 The nurse should be alert for an increase in serosanguineous

drainage from the wound.
is necessary.
 The nurse should administer cough suppressant to prevent
wound dehiscence.
is necessary.
INCORRECT
 The condition is an emergency that requires surgical repair.

is necessary.
Question 9 of 10
A postoperative diabetic patient had an
exploratory laparotomy (incision in the
abdomen) 5 days ago. The patient’s history
indicates obesity with a body mass index
(BMI) of 32 and smoking 1 pack/day. Based on
this information, the nurse understands the
patient should be observed for:
INCORRECT
 Developing a blood clot.

This patient is at risk for poor wound healing as a result of the
chronic illness of diabetes, being obese (BMI > 30), and
smoking. Fatty tissue has a poor blood supply for healing and
smoking increases the patient’s likelihood of coughing. The
nurse should observe for an increase in serosanguineous
drainage, an indication of potential dehiscence. The nurse
should teach the patient to splint the abdomen with a pillow when
coughing as a sudden strain on the incision could lead to
dehiscence.
 Developing a fistula.
dehiscence.
 Hemorrhage.
dehiscence.
CORRECT
 Wound dehiscence.
dehiscence.
Question 10 of 10
Which of the following may indicate internal
hemorrhage? (Select all that apply.)
CORRECT
 A decreased blood pressure and increased pulse.

The nurse can detect internal bleeding by looking for distention
or swelling of the affected body part, a change in the type and
amount of drainage from a surgical drain, or signs of
hypovolemic shock such as a decreased blood pressure,
increased pulse, and cool, clammy skin. An elevated white blood
cell count, purulent drainage and tenderness at wound site would
be an indication of infection.
CORRECT
 A change in the type and amount of drainage from a surgical

drain.
CORRECT
 Distention or swelling of the affected body part.

 An elevated white blood cell count.
INCORRECT
 Purulent drainage and tenderness at wound site.

Question 2 of 10
A contaminated or traumatic wound may show
signs of infection within 24 hours. A surgical
wound infection usually develops
postoperatively within 14 days.
CORRECT
 False
A contaminated or traumatic wound may show signs of infection
early, within 2 to 3 days. A surgical wound infection usually
develops postoperatively within 4 to 5 days.
 True
A contaminated or traumatic wound may show signs of infection
early, within 2 to 3 days. A surgical wound infection usually
develops postoperatively within 4 to 5 days.
Question 3 of 10
Healing by primary intention is expected when
the edges of a clean surgical incision are
sutured or stapled together, tissue loss is
minimal or absent, and the wound is
uncontaminated by microorganisms.
CORRECT
 True
This is the correct definition of healing by primary intention.
 False
This is the correct definition of healing by primary intention.
Question 8 of 10
The nurse reports that a patient has a wound
on his abdomen that is healing by secondary
intention. The nurse understands this means
the patient:
 Is at greater risk for wound dehiscence.
Healing by secondary intention indicates the patient has a wound
where there is tissue loss and the wound edges are not well
approximated. There is greater opportunity for development of
infection without the protective epidermal barrier and longer
healing time.
 has a drain.
healing time.
CORRECT
 Is at greater risk for infection.

healing time.
 Is healing naturally.
healing time.
Question 1 of 6
Match the illustration to the correct stage of
pressure injury.
 Stage 1 pressure injury.


Question 2 of 6
The nurse is observing the patient's wife
perform treatment of her husband's pressure
injury. Which action, if made by the patient's
wife, indicates that further instruction is
needed?
INCORRECT
 She premedicates the patient for pain before beginning the

dressing change.
To avoid transfer of microorganisms, the caretaker should apply
nonsterile gloves to remove the old dressing and discard the
gloves and old dressing materials in a plastic bag. She should
perform hand hygiene and apply new gloves before beginning to
cleanse the wound. She should use the ordered solution, most
generally normal saline, because soap can be very drying to
tissues and may leave a residue.
 She applies solution to the gauze and wrings out any excess.
She unfolds the gauze and packs the wound with the moistened
dressing. She covers the gently packed wound with dry 4 × 4–
inch gauze pads and applies tape to secure the dressing. She
removes her gloves and performs hand hygiene.
 While wearing gloves, she rinses the injury with normal
saline, gently wiping around the wound base and surrounding
skin with moistened gauze.
CORRECT
 She performs hand hygiene and removes the old dressing

and begins to clean the injury with soap and water.
Question 3 of 6
A family member calls the nurse to ask for
advice regarding their mother who has
developed a “bedsore” on her right heel. The
family member describes the pressure injury
as “a blister that has now popped and you can
see redness.” Based on this description, at
what stage would the nurse classify this
pressure injury?
INCORRECT
 Stage 1.
A stage 2 pressure injury can be described as an abrasion, a
blister, or shallow crater with skin loss involving the epidermis
and/or dermis. A stage 1 pressure injury appears as an area of
color change (e.g., persistent redness) on intact skin. A stage 3
pressure injury presents clinically as a deep crater. A stage 4
pressure injury involves bone, muscle, or supporting structures.
 Stage 4.
CORRECT
 Stage 2.
 Stage 3.
Question 4 of 6
Which of the following are common sites for
the development of pressure injuries? (Select
all that apply.)
CORRECT
 Trochanters.
Common sites for the development of pressure injuries include
the sacrum, heels, elbows, lateral malleoli, trochanters, and
ischial tuberosities.
INCORRECT
 Sternum.
CORRECT
 Ischial tuberosities.
CORRECT
 Sacrum.
CORRECT
 Heels.
CORRECT
 Lateral malleoli.
Question 5 of 6
Identify contributing factors to pressure injury
formation. (Select all that apply.)
CORRECT
 Anemia.
Three pressure-related forces contribute to the development of a
pressure injury: intensity of pressure (how much pressure is
applied), duration of pressure (how long the pressure is applied),
and tissue tolerance (the ability of the tissue to redistribute the
weight). Having decreased mobility or decreased ability to
perceive the need to shift one's weight or change position places
an individual at risk for pressure injury development. Three
extrinsic factors, shear, friction, and moisture, make the tissues
less tolerant of pressure. Other factors important in pressure
injury development include poor nutrition, advanced age, medical
conditions that support poor tissue perfusion (low blood
pressure, smoking, elevated temperature, anemia), and
psychosocial status, in particular stress-induced cortisol
secretion.
 Ethnic background.
secretion.
CORRECT
 Malnutrition.
secretion.
 Middle age.
secretion.
CORRECT
 Decreased sensory perception/mobility.

secretion.
CORRECT
 Excessive sweating.
secretion.
Question 6 of 6
Identify prevention strategies for pressure
injuries. (Select all that apply.)
INCORRECT
 Maintain the head of the bed at 45 degrees.

Patients should be repositioned every 2 hours to reduce the
duration and intensity of pressure. The 30-degree lateral position
avoids direct contact of the trochanter with the support surface.
Placing the patient on a pressure-reducing support surface
reduces the amount of pressure exerted against the tissues. The
head of the bed should be maintained at 30 degrees. If the head
is elevated more than this, it can increase the potential of the
patient to slide toward the foot of the bed and incur a shear
injury. Massaging reddened areas increases breaks in the
capillaries in the underlying tissues and increases the risk of
injury to underlying tissue, and therefore it should be avoided. A
moisture barrier ointment protects reddened intact skin from
incontinence. There is a strong relationship between poor
nutrition and pressure injury development. Supplements may
provide lacking nutrients.
 Massage reddened bony prominences.
CORRECT
 Place patient on a pressure-reducing support surface.

 Reposition patient at least every 4 hours; use a documented
schedule.
CORRECT
 Oral supplements should be instituted if the patient is found to

be undernourished.
CORRECT
 When the patient is in the side-lying position in bed, use the

30-degree lateral position.
Question 2 of 10
Match the description to the correct term.
Clear plasma.
 Serous.
Pink; mixture of blood and plasma.

 Serosanguineous.
Thick, yellow, green, tan, or brown.

 Purulent.
Bright red: indicates active bleeding.

 Sanguineous.
Question 3 of 10
Match the unexpected outcome to the related
intervention.
Keep patient on NPO (nothing-by-mouth) status because it
may be necessary to return to surgery.
 An excessive amount of bright bloody drainage
accumulates in the collection device over a short time
(e.g., 4 hours) indicating hemorrhage.
Assess for fever, elevated white blood cell count, redness,

swelling, and increasing pain.
 Wound infection develops.
Assess for tension on drainage tubing and secure tubing to

prevent pulling.
 Bleeding is present in and around drainage collector.
Assess drainage tubing for clots or kinks.

 Drainage system is empty although wound drainage is
increased on dressing.
Stabilize drainage tubing. Medicate patient.

 Pain can result from manipulation of the drainage
device or accumulation of drainage within the wound.
Question 4 of 10
The patient asks the nurse what the purpose is
for his Hemovac drain. What is the nurse's
best response?
CORRECT
 "To provide suction to remove and collect drainage from your

wound to help it heal."
The correct response would be "To provide constant suction to
remove and collect drainage from your wound to help it heal."
Although a Hemovac drain will collect drainage, the Hemovac
drain is used to provide constant low-pressure suction to remove
and collect drainage from the wound bed to allow the tissues to
come together to heal. Measuring the amount of drainage is
used to determine when the drain may be removed.
INCORRECT
 "To prevent infection and crust formation at the wound site."

 "To reduce the need for frequent dressing changes."
 "To accurately determinine fluid loss and whether your fluids
need to be increased."
Question 5 of 10
A patient is to go home with a Jackson-Pratt
drain. Which of the following statements, if
made by the patient, indicates further teaching
is required?
 "I should empty the drain when it is one-half to two-thirds full."
If drainage suddenly stops, the drainage tubing may have a
blockage. Notify the health care provider. The drain reservoir
should be emptied every 8 hours or less if the reservoir becomes
one-half to two-thirds full. The patient should keep a record of
the drain's output in 24 hours to aid in determining whether the
amount is decreasing as expected and when the drain may be
removed. The reservoir should remain compressed to provide a
constant low suction.
 "I should keep a record of how much drainage I empty."
INCORRECT
 "The bulb of the drain should remain compressed."

CORRECT
 "If drainage suddenly stops, it means the drain is ready to be

removed."
Question 6 of 10
When should wound drainage be cultured?
 If the nurse empties the drainage evacuator without applying
sterile gloves.
Wound drainage should be cultured when infection is suspected,
as indicated by the drainage appearing to be purulent, a change
in the amount or color of the wound drainage, or a foul odor of
the drainage being noted. It is appropriate for the nurse to wear
clean gloves to empty the drainage evacuator.
CORRECT
 When there is a change in color, amount, or odor of drainage.

INCORRECT
 When the drain is removed.

 If the patient complains of pain.
Question 7 of 10
The nurse is teaching a patient how to empty
his Hemovac drain. Which action of the patient
indicates that further instruction is needed?
The patient:
 holds the surfaces of the Hemovac together with one hand,
cleans the opening and plug with an alcohol swab with the other
hand, and immediately replaces the plug.
The patient must reestablish the vacuum for the Hemovac to be
effective. To reestablish the vacuum, the patient needs to press
the bottom and the top of the Hemovac together.
INCORRECT
 presses downward until the bottom and top of the Hemovac

are in contact to reestablish the vacuum.
CORRECT
 empties the Hemovac drain, replaces the plug, and records
the amount of drainage.
 opens the plug on the port for emptying the drainage reservoir
and drains the contents into the measuring container.
Question 8 of 10
Because a patient has a Penrose drain, the
nurse inspects the patient's skin and changes
the dressing by placing a drainage sponge
around the drain. What is the rationale for
doing this?
CORRECT
 Because drainage can be irritating to the skin and may cause

skin breakdown.
A Penrose drain does not have a collection device. Therefore the
nurse should inspect the skin and change the dressings as
needed to prevent skin breakdown. A Penrose drain does not
have a reservoir to compress. A safety pin is inserted through a
Penrose drain to prevent the tubing from migrating into the
wound. Although a Penrose drain may be advanced as the
wound heals, this is not the rationale for the nurse's inspection
and changing of the drainage sponges.
 Because a Penrose drain has to be frequently compressed to
create a constant low-pressure suction.
INCORRECT
 To prevent the tubing from migrating into the wound.

 To advance the tube as the wound heals.
Question 9 of 10
Which of the following is inappropriate to
delegate to nursing assistive personnel
(NAP)?
 Reporting the amount on the patient's intake and output
record.
Assessment of wound drainage and maintenance of drains and
the drainage system require the critical thinking and knowledge
application unique to a nurse and therefore are inappropriate to
delegate to NAP.
CORRECT
 Assessment of wound drainage.

delegate to NAP.
 Emptying a closed drainage container.
delegate to NAP.
INCORRECT
 Measuring the amount of drainage.

delegate to NAP.
Question 10 of 10
The patient complains "It feels like the drain is
pulling on my surgical site." What is the
nurse’s best action?
 Instruct the patient that this is the normal sensation of having
a drain.
To avoid pulling at the insertion site, the nurse should be sure
there is slack in the tubing from the reservoir to the wound,
allowing the patient movement. To facilitate drainage, the nurse
should secure the drain below the incision to the dressing with
tape and a safety pin and instruct the patient to keep the drain
below the insertion site when ambulating, sitting, and lying. If the
patient is complaining of pain, the nurse should further assess
the patient to determine if there is undue tension on the drain
tubing. The nurse should not advance the tube into the patient
because this would introduce microorganisms.
 Have the patient lie down and advance the drain further into
the patient until the sensation is relieved and drainage is noted in
tubing; secure a new dressing over insertion site of drain.
CORRECT
 Make sure there is slack in the tubing from the reservoir to the
wound, allowing the patient movement and avoiding pulling at
the insertion site.
INCORRECT
 Secure the drain above the incision to the dressing with tape
and a safety pin and instruct the patient to keep the drain above
the insertion site when ambulating, sitting, and lying.
Question 1 of 10
Match the description to the correct image.
 Soft rubber drain that removes drainage from the
wound depositing it on the skin surface.

 A drainage system used for larger amounts (up to 500
mL) of drainage.
 Used when small amounts (100 to 200 mL) of drainage
are anticipated.
Question 4 of 10
A patient asks the nurse why the Montgomery
ties are being used instead of regular tape.
What is the nurse's best response?
 "Montgomery ties can be tied tighter, providing a more secure
dressing and greater support of the wound."
Frequent removal of tape for dressing changes is irritating to the
skin. Montgomery straps are wide tapes with holes to use with
ties that secure dressings and facilitate changes without
removing the tape each time. Some patients are allergic to
adhesive. These patients often benefit from paper or
nonallergenic tape. Transparent dressings allow the wound to
"breathe."
 "Montgomery ties allow the wound to breathe."
"breathe."
 "Because Montgomery ties are nonallergenic."
"breathe."
CORRECT
 "Montgomery ties avoid frequent removal of tape, which is

irritating to the skin during dressing changes."
"breathe."
Question 1 of 10
Match the appropriate intervention to the
unexpected outcome.
Provide additional teaching and support. Obtain services of
home care agency as needed.
 Patient or caregiver is unable to perform dressing
change.
Observe color and amount of bloody drainage. If

excessive, apply direct pressure. Obtain vital signs. Notify
health care provider.
 Wound bleeds during dressing change.
Monitor patient for signs of infection, such as fever,

increased white blood cell (WBC) count, and purulent
drainage. Notify health care provider. Obtain wound
cultures as ordered.
 Wound appears inflamed and tender, drainage is
evident, and/or odor is present.
Observe wound for increased drainage or dehiscence or

evisceration. Cover wound with sterile moist dressing if
necessary. Instruct patient to lie still. Notify health care
provider.
 Patient reports a sensation that "something has given
way under the dressing."
Question 2 of 10
During a sterile dressing change, when are the
gloves changed?
 After the old dressing is removed, after cleansing the wound,
and before applying a new dressing.
Gloves are discarded after removing the old dressing. If required,
a sterile field is then prepared, new sterile gloves are applied,
and the wound is cleansed. It is unnecessary to change the
gloves frequently unless they are accidentally contaminated.
Gloves are changed after removing the old dressing and before
cleaning the wound to reduce transmission of cross-
contamination from microorganisms. The same gloves may then
be worn for applying a new dressing. With chronic wounds, clean
gloves may be worn rather than sterile gloves (check agency
policy).
CORRECT
 After the old dressing is removed and before cleansing the

wound.
Gloves are discarded after removing the old dressing. If required, a sterile field is
then prepared, new sterile gloves are applied, and the wound is cleansed. It is
unnecessary to change the gloves frequently unless they are accidentally
contaminated. Gloves are changed after removing the old dressing and before
cleaning the wound to reduce transmission of cross-contamination from
microorganisms. The same gloves may then be worn for applying a new
dressing. With chronic wounds, clean gloves may be worn rather than sterile
gloves (check agency policy).
 It is unnecessary to change gloves for chronic wounds.
policy).
INCORRECT
 After the old dressing is removed and before creating a sterile

field.
policy).
Question 3 of 10
A patient states that she is unable to get her
transparent dressing to stay in place. What
instruction should the nurse provide the
patient?
 "There are many options on the market. Why don't you try to
use a non-adhesive-backed transparent dressing instead?"
If the transparent dressing does not stay in place, the size of the
dressing should be evaluated for adequate (1 to 1.5 inches or
2.5 to 3.75 cm) margin, and the skin should be dried thoroughly
before reapplication. The patient requires further instruction, not
necessarily a referral, regarding interventions to aid in dressing
adherence. The dressing coming off is an unexpected outcome.
Blaming the patient is nontherapeutic.
CORRECT
 "Make sure that you have a margin of 1 to 1.5 inches (2.5 to

3.75 cm) around the wound, and that the skin is thoroughly dry
before applying the dressing."
 "This type of dressing requires frequent changing because
they do not stay in place."
INCORRECT
 "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."
 "You probably are applying it incorrectly, or perhaps you are
just too anxious about having to perform the dressing change."
Question 5 of 10
How can the nurse determine that negative
pressure is being achieved with a wound
V.A.C.?
CORRECT
 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.
The nurse should inspect the wound V.A.C. system to verify that
negative pressure is being achieved: Verify that the display
screen reads “Therapy On”; be sure the clamps are open and
tubing is patent; identify air leaks by listening with a stethoscope
or by moving hand around edges of the wound while applying
light pressure; and if a leak is present, use strips of transparent
film to patch areas around the edges of the wound. Negative
pressure is achieved when an airtight seal is achieved. The
wound V.A.C. will sound an alarm if the canister is improperly
engaged or if the unit is tilted beyond 45 degrees.
 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.
INCORRECT
 The nurse can ensure that the foam is in contact with the
entire wound base, margins, and tunneled and undermined
areas.
 The nurse can ensure that there is no whistling noise at the
wound site and that the wound V.A.C. has not triggered its
alarm.
Question 6 of 10
Which of the following is a correct sequence
for changing a gauze dressing?
CORRECT
 Remove old dressing, discard gloves and perform hand

hygiene, create sterile field, apply sterile gloves, clean wound,
blot dry, apply new dressing.
The nurse should remove the old dressing, inspect the wound,
dispose of gloves and soiled dressings, and perform hand
hygiene. The nurse then creates a sterile field, applies new
sterile gloves, and cleans the wound from least contaminated
(the surgical incision) to the most contaminated (the drain). The
nurse dries the area in the same manner and puts on the new
dressing.
 Remove old dressing, discard gloves, apply new gloves, and
apply new dressing.
dressing.
INCORRECT
 Remove old dressing, discard gloves, clean wound, apply

loose woven gauze, and cover with thicker woven pad (e.g., ABD
pad).
dressing.
 Create sterile field, remove old dressing, discard gloves and
perform hand hygiene, apply new gloves, clean wound, blot dry,
apply new dressing.
dressing.
Question 7 of 10
Which of the following are functions of
dressings? (Select all that apply.)
CORRECT
 Wound debridement.
Dressings provide several functions, which include debridement,
maintaining a moist wound environment, protecting from outside
contamination and further injury, preventing the spread of
microorganisms, increased patient comfort, and promoting
hemostasis by control of bleeding. Dressings are unable to
increase circulation.
CORRECT
 To promote hemostasis.
 To increase circulation.
CORRECT
 To prevent contamination.
 To keep the wound bed dry.
Question 8 of 10
Which of the following patients would be
expected to benefit from a damp-to-dry
dressing? (Select all that apply.)
CORRECT
 A 24-year-old patient with an open and infected wound from a

spider bite.
Damp-to-dry dressings are often used with necrotic, infected
wounds requiring debridement. Moist dressings are often used
for helping to heal full-thickness wounds that look like craters.
Dry woven gauze dressings, or nonstick dressings are most
often used for abrasions, superficial lacerations and
postoperative incisions when minimal drainage is anticipated.
 A 50-year-old with a postoperative knee-replacement incision.
 A 19-year-old with a superficial laceration on the arm.
CORRECT
 A 30-year-old after large cyst removal with necrotic tissue

present in crater-type wound.
 A 7-year-old with abrasions on the knees.
Question 9 of 10
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 that further instruction is
needed? (Select all that apply.)
 When removing the old dressing the wife leaves the dressing
dry, even when it sticks slightly.
Inner gauze should be moist to absorb drainage and adhere to
debris. The wound should be loosely packed to facilitate wicking
of drainage into the absorbent outer layer of the dressing. The
wound should never be overpacked because this can cause
wound trauma when the dressing is removed. Premedicating for
pain will help provide comfort during the dressing change. If
dressing sticks on a damp-to-dry dressing, the wife should gently
free the dressing and alert the patient of discomfort. The wife
was correct in not wetting the dressing because a damp-to-dry
dressing should debride the wound. The wife is correct to pull the
tape towad the wound to avoid pulling on the wound edges.
INCORRECT
 Pulls tape in direction toward wound when removing previous

dressing.
CORRECT
 Packs wound tightly.

CORRECT
 Leaves contact or primary dressing dripping moist.

 Premedicates for pain.
Question 10 of 10
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.)
CORRECT
 Decrease the pressure setting.

Patients may experience more pain with the black foam because
of excessive wound contraction. For this reason, they may need
to be switched to the PVA soft foam. Administering pain
medication can help alleviate pain, and decreasing the pressure
setting may also help reduce pain.
CORRECT
 Administer pain medication.

 Switch to the black polyurethane (PU) foam.
CORRECT
 Switch to the white polyvinyl alcohol (PVA) soft foam.

 Keep the suction in the "off" position.
Question 3 of 5
While removing the patient’s staples, the
nurse notices that the incision starts to open
larger than the width of two staples. Which
action should the nurse initially take?
INCORRECT
 Notify the health care provider of the opening in the wound.

Steri-Strip would be applied first to prevent any further opening
of the incision. The patient’s physical needs must be met first.
The health care provider would be notified, and the wound status
documented. No further staples should be removed at this time.
The staples may need to remain in longer.
CORRECT
 Place several Steri-Strip to close the open area.

 Remove one more staple to see whether the open area
enlarges.
 Palpate the edges of the wound.
Question 5 of 5
An older diabetic patient with a lot of
abdominal fat underwent abdominal surgery 4
days ago involving an 8-inch vertical incision.
The nurse would be most concerned if which
observation of the incision was made?
INCORRECT
 The incision line has a light crust on it.

An increase in serosanguineous drainage is an early indication
that the wound is not healing as expected, and that dehiscence
could occur. The patient is obese, is advanced in age, and has
diabetes—all of which are stressors that could cause a negative
outcome.
 The patient’s pain level has changed from “5” yesterday to “2”
today.
outcome.
CORRECT
 Serosanguineous drainage has increased since 2 days ago.

outcome.
 The incision line is slightly pink and elevated where the
staples are located.
outcome.
Question 1 of 5
The patient asks the nurse why he has a drain
in his abdomen after surgery. Which response
by the nurse is most accurate?
CORRECT
 “The drain removes fluid from the surgical area to promote

healing.”
The drain removes any accumulation of drainage from the
wound bed, and this promotes wound healing. The answer is
truthful and uses no technical words.
 “The drain removes abdominal fluids to reduce stress on the
suture line.”
 “You have a drain to prevent any swelling of the surgical
area.”
 “The drain allows the antibiotics that were instilled in the
wound to drain.”
Question 2 of 5
A patient with a large abdominal incision is
being discharged. Which statement by the
patient indicates that teaching by the nurse
has been effective?
CORRECT
 “I need to avoid lifting anything heavy for at least several

weeks.”
Lifting heavy objects can cause a strain on the suture line and
must be avoided for several weeks. An incision without staples is
still healing and will not contain strong tissue, thus it could still be
vulnerable to damage. Drainage would be minimal but could still
occur.
 “As long as I don’t have pain, I can do just about anything I
want.”
occur.
 “Now that my incision is without staples, it is healed and
strong.”
occur.
 “I don’t have to worry about further drainage, now that the
staples are out.”
occur.
Question 4 of 5
A patient needs to have his abdominal wound
irrigated. Which part of the procedure may the
nurse delegate to nursing assistive personnel
(NAP)?
CORRECT
 Taping the dressing once the wound is covered

Nursing assistive personnel cannot have wound irrigation
delegated to them. Because they may cleanse chronic wounds
using clean technique, the NAP would be able to tape the
dressing after the irrigation, once it has been covered by the
nurse.
 Documenting the description of the wound
nurse.
 Performing wound irrigation
nurse.
 Packing the wound with sterile gauze pads
nurse.

Question 1 of 10: Match The Potential Complication To The Symptoms

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Question 1 of 10: Match The Potential Complication To The Symptoms

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Abnormal passage between two organs, chronic drainage.

Increased white blood cell count, fever, purulent drainage.

Hypotension, tachycardia, hematoma formation.

Partial or total separation of wound layers; patient states

 A 17-year-old patient who has a metal fragment lodged in his

 A 30-year-old woman who had an episiotomy with childbirth.

 Inadequate nutrition delays wound healing and increases risk

 The patient is demonstrating signs of a postoperative wound

 The nurse should be alert for an increase in serosanguineous

 The condition is an emergency that requires surgical repair.

 Developing a blood clot.

 A decreased blood pressure and increased pulse.

 A change in the type and amount of drainage from a surgical

 Distention or swelling of the affected body part.

 Purulent drainage and tenderness at wound site.

 Is at greater risk for infection.

 Stage 1 pressure injury.

 Stage 3 pressure injury.

 She premedicates the patient for pain before beginning the

 She performs hand hygiene and removes the old dressing

 Decreased sensory perception/mobility.

 Maintain the head of the bed at 45 degrees.

 Place patient on a pressure-reducing support surface.

 Oral supplements should be instituted if the patient is found to

 When the patient is in the side-lying position in bed, use the

Pink; mixture of blood and plasma.

Thick, yellow, green, tan, or brown.

Bright red: indicates active bleeding.

accumulates in the collection device over a short time

(e.g., 4 hours) indicating hemorrhage.

Assess for fever, elevated white blood cell count, redness,

Assess for tension on drainage tubing and secure tubing to

Assess drainage tubing for clots or kinks.

Stabilize drainage tubing. Medicate patient.

device or accumulation of drainage within the wound.

 "To provide suction to remove and collect drainage from your

 "To prevent infection and crust formation at the wound site."

 "The bulb of the drain should remain compressed."

 "If drainage suddenly stops, it means the drain is ready to be

 When there is a change in color, amount, or odor of drainage.

 When the drain is removed.

 presses downward until the bottom and top of the Hemovac

 Because drainage can be irritating to the skin and may cause

 To prevent the tubing from migrating into the wound.

 Assessment of wound drainage.

 Measuring the amount of drainage.

 Soft rubber drain that removes drainage from the

wound depositing it on the skin surface.

 Used when small amounts (100 to 200 mL) of drainage

 "Montgomery ties avoid frequent removal of tape, which is

Observe color and amount of bloody drainage. If

Monitor patient for signs of infection, such as fever,

evident, and/or odor is present.

Observe wound for increased drainage or dehiscence or

way under the dressing."

 After the old dressing is removed and before cleansing the

 After the old dressing is removed and before creating a sterile

 "Make sure that you have a margin of 1 to 1.5 inches (2.5 to

 "If you are having difficulty with your dressing changes, we

 The nurse can check for air leaks by listening with a

 Remove old dressing, discard gloves and perform hand

 Remove old dressing, discard gloves, clean wound, apply