NSG 3100 EXAM 2 WOUND CARE QUESTIONS AND
ANSWERS
The continuous quality improvement team is monitoring the nursing care of clean-
contaminated wounds. Which operative wound would be excluded from this study?
1. Gastric resection
2. Uncomplicated abdominal hysterectomy
3. Breast biopsy
4. Lung resection - Answers - 3. Breast biopsy
Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory,
alimentary, genital, or urinary tract has been entered. These wounds show no evidence
of infection. A gastric resection would be included in the study.
The surgical report of a newly transferred client indicates that there was a great deal of
intestinal spillage into the abdominal cavity during the clients bowel resection. For which
category of wound should the receiving nurse plan care for this client?
1. Clean-contaminated
2. Contaminated
3. Dirty
4. Infected - Answers - 2. Contaminated
Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory,
alimentary, genital, or urinary tract has been entered, but minimal to no spillage has
occurred.
A client has sustained multiple contusions from a motor vehicle accident. What should
the nurse do to prepare for this clients care?
1. Obtain ice packs to apply to the wounds.
2. Request gauze to pack the wounds.
3. Organize suture material to close the wounds.
4. Notify the surgical staff that a surgical client will soon be arriving. - Answers - 1.
Obtain ice packs to apply to the wounds.
Rationale 1: Contusions are closed wounds in which the skin is ecchymotic or bruised
due to damage of blood vessels. These wounds are treated with ice pack application for
the first 24 hours.
After completing a scheduled every-2-hour turn by turning the client to the left side, the
nurse notices a reddened area over the coccyx. The area blanches when the nurse
compresses it with thumb pressure. One hour later, the nurse reassesses the area and
finds the redness has disappeared. How should the nurse document this area?
1. Reactive hyperemia
2. Stage I pressure ulcer
3. Stage II pressure ulcer
4. Stage III pressure ulcer - Answers - 1. Reactive hyperemia
, Rationale 1: If the reddened area blanches with thumb pressure and disappears in one-
half to three-quarters of the time pressure was on the area, the condition is reactive
hyperemia and no damage to the skin and tissues has occurred.
The nurse assesses an open area over a clients greater trochanter that is approximately
10 cm in diameter. The tissue around the area is edematous and feels boggy. The
edges of the wound cup in toward the center. Which additional finding would indicate to
the nurse that this is a stage IV pressure ulcer?
1. There is undermining of adjacent tissues.
2. The crater extends into the subcutaneous tissue.
3. The joint capsule of the hip is visible.
4. The ulcer has thick dark eschar over the top. - Answers - 3. The joint capsule of the
hip is visible.
Rationale 1: Undermining of adjacent tissues can occur in either a stage III or stage IV
pressure ulcer.
The UAP reports a small skin tear on the clients forearm that occurred during a routine
turn. After assessing the wound the nurse should take which action?
1. Obtain a transparent dressing for the UAP to place on the wound.
2. Request a consult with the wound care nurse.
3. Cleanse the wound and apply a dressing.
4. Tell the UAP to reevaluate the wound in 20 minutes. - Answers - 3. Cleanse the
wound and apply a dressing.
Rationale 1: The UAP is not educationally prepared to dress the wound.
The newly hired nurse learns that the facility uses the Braden Scale for Predicting
Pressure Sore Risk to assess all new admissions. Before using this scale the nurse
1. should receive specific training.
2. must be certified.
3. is required to ask the clients permission.
4. has to obtain special assessment equipment. - Answers - 1. should receive specific
training.
Rationale 1: The nurse should receive specific training in the use of the Braden scale in
order for assessment to be accurate.
A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the
last 2 months. What does the nurse determine as the significance of the trending of
these scores?
1. Trending can only be accurate if the same scale is used.
2. There is a definite trend of low risk for pressure ulcer development.
3. Trending would be more accurate if the same scale was used.
4. The scores indicate opposite risks for pressure ulcer development. - Answers - 3.
Trending would be more accurate if the same scale was used.
Rationale 1: All of these scores indicate risk for development of a pressure ulcer, so
some trending is possible, but it would be more accurate if the same scale was always
used.
ANSWERS
The continuous quality improvement team is monitoring the nursing care of clean-
contaminated wounds. Which operative wound would be excluded from this study?
1. Gastric resection
2. Uncomplicated abdominal hysterectomy
3. Breast biopsy
4. Lung resection - Answers - 3. Breast biopsy
Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory,
alimentary, genital, or urinary tract has been entered. These wounds show no evidence
of infection. A gastric resection would be included in the study.
The surgical report of a newly transferred client indicates that there was a great deal of
intestinal spillage into the abdominal cavity during the clients bowel resection. For which
category of wound should the receiving nurse plan care for this client?
1. Clean-contaminated
2. Contaminated
3. Dirty
4. Infected - Answers - 2. Contaminated
Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory,
alimentary, genital, or urinary tract has been entered, but minimal to no spillage has
occurred.
A client has sustained multiple contusions from a motor vehicle accident. What should
the nurse do to prepare for this clients care?
1. Obtain ice packs to apply to the wounds.
2. Request gauze to pack the wounds.
3. Organize suture material to close the wounds.
4. Notify the surgical staff that a surgical client will soon be arriving. - Answers - 1.
Obtain ice packs to apply to the wounds.
Rationale 1: Contusions are closed wounds in which the skin is ecchymotic or bruised
due to damage of blood vessels. These wounds are treated with ice pack application for
the first 24 hours.
After completing a scheduled every-2-hour turn by turning the client to the left side, the
nurse notices a reddened area over the coccyx. The area blanches when the nurse
compresses it with thumb pressure. One hour later, the nurse reassesses the area and
finds the redness has disappeared. How should the nurse document this area?
1. Reactive hyperemia
2. Stage I pressure ulcer
3. Stage II pressure ulcer
4. Stage III pressure ulcer - Answers - 1. Reactive hyperemia
, Rationale 1: If the reddened area blanches with thumb pressure and disappears in one-
half to three-quarters of the time pressure was on the area, the condition is reactive
hyperemia and no damage to the skin and tissues has occurred.
The nurse assesses an open area over a clients greater trochanter that is approximately
10 cm in diameter. The tissue around the area is edematous and feels boggy. The
edges of the wound cup in toward the center. Which additional finding would indicate to
the nurse that this is a stage IV pressure ulcer?
1. There is undermining of adjacent tissues.
2. The crater extends into the subcutaneous tissue.
3. The joint capsule of the hip is visible.
4. The ulcer has thick dark eschar over the top. - Answers - 3. The joint capsule of the
hip is visible.
Rationale 1: Undermining of adjacent tissues can occur in either a stage III or stage IV
pressure ulcer.
The UAP reports a small skin tear on the clients forearm that occurred during a routine
turn. After assessing the wound the nurse should take which action?
1. Obtain a transparent dressing for the UAP to place on the wound.
2. Request a consult with the wound care nurse.
3. Cleanse the wound and apply a dressing.
4. Tell the UAP to reevaluate the wound in 20 minutes. - Answers - 3. Cleanse the
wound and apply a dressing.
Rationale 1: The UAP is not educationally prepared to dress the wound.
The newly hired nurse learns that the facility uses the Braden Scale for Predicting
Pressure Sore Risk to assess all new admissions. Before using this scale the nurse
1. should receive specific training.
2. must be certified.
3. is required to ask the clients permission.
4. has to obtain special assessment equipment. - Answers - 1. should receive specific
training.
Rationale 1: The nurse should receive specific training in the use of the Braden scale in
order for assessment to be accurate.
A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the
last 2 months. What does the nurse determine as the significance of the trending of
these scores?
1. Trending can only be accurate if the same scale is used.
2. There is a definite trend of low risk for pressure ulcer development.
3. Trending would be more accurate if the same scale was used.
4. The scores indicate opposite risks for pressure ulcer development. - Answers - 3.
Trending would be more accurate if the same scale was used.
Rationale 1: All of these scores indicate risk for development of a pressure ulcer, so
some trending is possible, but it would be more accurate if the same scale was always
used.
