1|Page
Wound Care Final Quiz 2026–2027 Latest Update | Comprehensive Practice
Questions, Detailed Answer Explanations, Complete Study Review & Exam
Preparation Guide PDF
## Exam Coverage Summary
This comprehensive Wound Care examination covers all essential domains including: pressure ulcer pathophysiology and
prevention (intensity and duration of pressure, tissue tolerance, intrinsic and extrinsic factors); wound healing phases and types
(primary, secondary, tertiary intention); wound assessment and documentation (size, depth, tunneling, undermining, drainage
characteristics); pressure ulcer staging (Stage 1-4 and unstageable, deep tissue injury); wound complications (infection,
dehiscence, evisceration, hematoma, fistula); wound cleansing and irrigation techniques (circular motions, appropriate solutions,
drying methods); dressing selection and application (occlusive dressings, hydrocolloids, transparent films, gauze); drainage
systems (Penrose drains, Jackson-Pratt, Hemovac, closed vs open systems); surgical wound care (incision assessment, suture
removal, staple care); debridement methods (autolytic, mechanical, surgical, enzymatic); negative pressure wound therapy;
nutritional considerations in wound healing (protein, vitamin C, zinc); patient positioning and pressure redistribution; infection
control and sterile technique; and documentation and legal considerations.
Multiple Choice Questions
1. The nurse recognizes that the primary cause of pressure ulcers involves which combination of factors?
A. Only the intensity of pressure applied to the tissue
B. The duration of pressure and the person's age alone
C. Intensity of pressure, duration of pressure, and the tissue's ability to tolerate pressure
D. Only extrinsic factors such as friction and shear
Pressure ulcers result from a combination of factors including the intensity of the pressure, the duration of pressure exposure, and
both intrinsic and extrinsic factors that affect the tissue's ability to tolerate pressure. Nutritional status and age are important
intrinsic factors that influence tissue tolerance.
2. The nurse is caring for a client who has experienced a total abdominal hysterectomy. Which nursing observation related to the
incision will indicate the client is experiencing a complication of wound healing?
A. The incision appears pink and is approximated with edges together
B. The client reports itching at the incision site
C. The incision appears both swollen and bluish in color
D. The client reports pain at the surgical site
A hematoma is a localized collection of blood underneath the tissues appearing as swelling, change in color (bluish
discoloration), sensation, or warmth. It can be dangerous if it puts pressure on major blood vessels and obstructs blood flow.
Itching, pain, and approximated edges with pink coloring are expected findings in normal healing.
3. The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates
a lack of understanding?
A. "Occlusive dressings provide a moist wound healing environment."
B. "Occlusive dressings are used for autolytic debridement."
C. "Occlusive dressings can be used on infected wounds."
D. "Occlusive dressings are the most comfortable form of debridement for the client."
Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and provide a moist wound
healing environment. However, they are contraindicated in infected wounds because they can trap bacteria and promote infection.
Autolytic debridement is considered the most comfortable form of debridement for the client.
4. The nurse is caring for a postoperative client recovering from a medial meniscus repair of the right knee. Which action should
the nurse take to assist with pain management?
A. Place the extremity in a dependent position
B. Apply ice to the surgical site
C. Check the pedal pulses
,2|Page
D. Monitor vital signs every 15 minutes
Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part, all of which contribute to pain
management. Elevation (not dependent position) helps prevent edema. Checking pulses monitors circulation but does not directly
manage pain. Monitoring vital signs includes pain assessment but is not an intervention that decreases pain.
5. The nurse understands which rationale to be appropriate for drying a wound after irrigation?
A. To prevent the dressing from sticking to the wound
B. To prevent skin breakdown from moisture
C. To prevent infection
D. To promote granulation tissue formation
Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being
removed and reduces trauma to the wound. The type of dressing determines how it lays in the wound and whether it is occlusive.
Drying does not directly prevent infection or promote granulation tissue.
6. The nurse inspects all wounds for signs of infection. When might a contaminated or traumatic wound show signs of infection?
A. Within 12 hours of injury
B. 2 to 3 days after injury
C. 4 to 5 days after injury
D. 7 to 10 days after injury
A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days after injury. A surgical wound infection
usually develops postoperatively within 4 to 5 days. Early identification of infection is crucial for prompt treatment and
prevention of complications.
7. The nurse is taking care of a post-surgical client and notes the incision is clean and dry, with sutures intact. The nurse further
assesses that the wound is healing by:
A. First (primary) intention
B. Second (secondary) intention
C. Third (tertiary) intention
D. Delayed primary closure
A wound with minimal tissue loss, such as a surgical incision, heals by closure, which is first or primary intention. Wounds that
are not closed heal by either second (secondary) intention (healing from the base up) or third (tertiary) intention (delayed closure
after infection or contamination is controlled).
8. The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:
A. From the outside of the wound toward the center
B. In a circular motion around the wound circling to the outside
C. Back and forth across the wound
D. From top to bottom only
A circular motion around the wound toward the outside keeps the wound area cleanest and prevents contamination of the wound
with microorganisms from the surrounding skin. Cleaning from the outside toward the center would push bacteria into the
wound. Back and forth or top to bottom motions do not provide optimal cleaning technique.
9. How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?
A. By connecting the drain to wall suction
B. By compressing the drain reservoir
C. By applying gravity drainage
D. By irrigating the drain with sterile saline
Compressing the surface of the Hemovac drain or the bulb of the Jackson-Pratt drain and quickly reinserting the cap re-
establishes the vacuum. Suction is never used with a Jackson-Pratt drain; these drains use the built-in reservoir compression to
create negative pressure. Gravity drainage is used for Penrose drains.
10. The nurse is repositioning the client in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the
nurse should place the head of the bed in which position?
A. 90 degrees
B. 45 degrees
, 3|Page
C. 30 degrees
D. 15 degrees
When side-lying, clients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the client directly on
bony prominences such as the head of the trochanter. A 30-degree lateral position reduces pressure on the greater trochanter and
sacrum, distributing pressure more evenly.
11. When the nurse is caring for a client with a Penrose drain, what care needs to be carried out?
A. The drain is connected to low intermittent suction
B. The drain is sutured securely in place
C. The drain is not sutured in place so care is taken to not dislodge it
D. The drain is compressed to re-establish vacuum
The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to
suction. Care must be taken to not dislodge it during dressing changes and patient movement. Closed drains such as Jackson-Pratt
or Hemovac are compressed or connected to suction if ordered.
12. Which of the following regarding removal of the old dressing on a surgical incision are accurate? (Select all that apply.)
A. Use caution to avoid tension on any drains that are present
B. Remove tape in the direction opposite to hair growth
C. If dressing is over a hairy area, remove tape in the direction of hair growth
D. Pull tape perpendicular to the skin, toward the dressing
Use caution to avoid tension on any drains that are present. If the dressing is over a hairy area, remove in the direction of hair
growth. Tape should be pulled parallel to the skin, in a direction toward the dressing to avoid pulling on the suture line. Remove
dressings one layer at a time, observing appearance and drainage with clean gloves.
13. The nurse is caring for a client with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that
apply.)
A. Place moist sterile gauze over the site
B. Place the client supine
C. Contact the surgical team
D. Allow the client to have clear liquids
The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical emergency. Immediately
place the client supine, place damp sterile gauze over the site, contact the surgical team, do not allow the client anything by
mouth (NPO), observe for signs and symptoms of shock, and prepare the client for emergency surgery.
14. When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?
A. A pressure ulcer that extends through the fascia to muscle
B. A pressure ulcer that does not extend through the fascia
C. A pressure ulcer that involves only the epidermis
D. A pressure ulcer with bone exposure
Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to
muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve
exposure of muscle, bone, or connective tissue. Stage 2 ulcers are partial-thickness involving epidermis and/or dermis.
15. The nurse is caring for a client with a deep wound that requires packing. Which of the following is the correct technique for
wound packing?
A. Pack the wound tightly to prevent bleeding
B. Loosely pack the wound to allow for drainage
C. Pack the wound only to the surface level
D. Use dry gauze to pack the wound
Wounds should be loosely packed to allow for drainage and to prevent trauma to granulation tissue. Tight packing can cause
tissue damage and impede healing. The packing should fill the wound space but not be tightly compressed, allowing wound fluid
to be absorbed and drainage to escape.
16. The nurse is assessing a wound and notes the presence of eschar. The nurse should document this finding as:
A. Healthy granulation tissue
Wound Care Final Quiz 2026–2027 Latest Update | Comprehensive Practice
Questions, Detailed Answer Explanations, Complete Study Review & Exam
Preparation Guide PDF
## Exam Coverage Summary
This comprehensive Wound Care examination covers all essential domains including: pressure ulcer pathophysiology and
prevention (intensity and duration of pressure, tissue tolerance, intrinsic and extrinsic factors); wound healing phases and types
(primary, secondary, tertiary intention); wound assessment and documentation (size, depth, tunneling, undermining, drainage
characteristics); pressure ulcer staging (Stage 1-4 and unstageable, deep tissue injury); wound complications (infection,
dehiscence, evisceration, hematoma, fistula); wound cleansing and irrigation techniques (circular motions, appropriate solutions,
drying methods); dressing selection and application (occlusive dressings, hydrocolloids, transparent films, gauze); drainage
systems (Penrose drains, Jackson-Pratt, Hemovac, closed vs open systems); surgical wound care (incision assessment, suture
removal, staple care); debridement methods (autolytic, mechanical, surgical, enzymatic); negative pressure wound therapy;
nutritional considerations in wound healing (protein, vitamin C, zinc); patient positioning and pressure redistribution; infection
control and sterile technique; and documentation and legal considerations.
Multiple Choice Questions
1. The nurse recognizes that the primary cause of pressure ulcers involves which combination of factors?
A. Only the intensity of pressure applied to the tissue
B. The duration of pressure and the person's age alone
C. Intensity of pressure, duration of pressure, and the tissue's ability to tolerate pressure
D. Only extrinsic factors such as friction and shear
Pressure ulcers result from a combination of factors including the intensity of the pressure, the duration of pressure exposure, and
both intrinsic and extrinsic factors that affect the tissue's ability to tolerate pressure. Nutritional status and age are important
intrinsic factors that influence tissue tolerance.
2. The nurse is caring for a client who has experienced a total abdominal hysterectomy. Which nursing observation related to the
incision will indicate the client is experiencing a complication of wound healing?
A. The incision appears pink and is approximated with edges together
B. The client reports itching at the incision site
C. The incision appears both swollen and bluish in color
D. The client reports pain at the surgical site
A hematoma is a localized collection of blood underneath the tissues appearing as swelling, change in color (bluish
discoloration), sensation, or warmth. It can be dangerous if it puts pressure on major blood vessels and obstructs blood flow.
Itching, pain, and approximated edges with pink coloring are expected findings in normal healing.
3. The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates
a lack of understanding?
A. "Occlusive dressings provide a moist wound healing environment."
B. "Occlusive dressings are used for autolytic debridement."
C. "Occlusive dressings can be used on infected wounds."
D. "Occlusive dressings are the most comfortable form of debridement for the client."
Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and provide a moist wound
healing environment. However, they are contraindicated in infected wounds because they can trap bacteria and promote infection.
Autolytic debridement is considered the most comfortable form of debridement for the client.
4. The nurse is caring for a postoperative client recovering from a medial meniscus repair of the right knee. Which action should
the nurse take to assist with pain management?
A. Place the extremity in a dependent position
B. Apply ice to the surgical site
C. Check the pedal pulses
,2|Page
D. Monitor vital signs every 15 minutes
Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part, all of which contribute to pain
management. Elevation (not dependent position) helps prevent edema. Checking pulses monitors circulation but does not directly
manage pain. Monitoring vital signs includes pain assessment but is not an intervention that decreases pain.
5. The nurse understands which rationale to be appropriate for drying a wound after irrigation?
A. To prevent the dressing from sticking to the wound
B. To prevent skin breakdown from moisture
C. To prevent infection
D. To promote granulation tissue formation
Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being
removed and reduces trauma to the wound. The type of dressing determines how it lays in the wound and whether it is occlusive.
Drying does not directly prevent infection or promote granulation tissue.
6. The nurse inspects all wounds for signs of infection. When might a contaminated or traumatic wound show signs of infection?
A. Within 12 hours of injury
B. 2 to 3 days after injury
C. 4 to 5 days after injury
D. 7 to 10 days after injury
A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days after injury. A surgical wound infection
usually develops postoperatively within 4 to 5 days. Early identification of infection is crucial for prompt treatment and
prevention of complications.
7. The nurse is taking care of a post-surgical client and notes the incision is clean and dry, with sutures intact. The nurse further
assesses that the wound is healing by:
A. First (primary) intention
B. Second (secondary) intention
C. Third (tertiary) intention
D. Delayed primary closure
A wound with minimal tissue loss, such as a surgical incision, heals by closure, which is first or primary intention. Wounds that
are not closed heal by either second (secondary) intention (healing from the base up) or third (tertiary) intention (delayed closure
after infection or contamination is controlled).
8. The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:
A. From the outside of the wound toward the center
B. In a circular motion around the wound circling to the outside
C. Back and forth across the wound
D. From top to bottom only
A circular motion around the wound toward the outside keeps the wound area cleanest and prevents contamination of the wound
with microorganisms from the surrounding skin. Cleaning from the outside toward the center would push bacteria into the
wound. Back and forth or top to bottom motions do not provide optimal cleaning technique.
9. How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?
A. By connecting the drain to wall suction
B. By compressing the drain reservoir
C. By applying gravity drainage
D. By irrigating the drain with sterile saline
Compressing the surface of the Hemovac drain or the bulb of the Jackson-Pratt drain and quickly reinserting the cap re-
establishes the vacuum. Suction is never used with a Jackson-Pratt drain; these drains use the built-in reservoir compression to
create negative pressure. Gravity drainage is used for Penrose drains.
10. The nurse is repositioning the client in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the
nurse should place the head of the bed in which position?
A. 90 degrees
B. 45 degrees
, 3|Page
C. 30 degrees
D. 15 degrees
When side-lying, clients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the client directly on
bony prominences such as the head of the trochanter. A 30-degree lateral position reduces pressure on the greater trochanter and
sacrum, distributing pressure more evenly.
11. When the nurse is caring for a client with a Penrose drain, what care needs to be carried out?
A. The drain is connected to low intermittent suction
B. The drain is sutured securely in place
C. The drain is not sutured in place so care is taken to not dislodge it
D. The drain is compressed to re-establish vacuum
The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to
suction. Care must be taken to not dislodge it during dressing changes and patient movement. Closed drains such as Jackson-Pratt
or Hemovac are compressed or connected to suction if ordered.
12. Which of the following regarding removal of the old dressing on a surgical incision are accurate? (Select all that apply.)
A. Use caution to avoid tension on any drains that are present
B. Remove tape in the direction opposite to hair growth
C. If dressing is over a hairy area, remove tape in the direction of hair growth
D. Pull tape perpendicular to the skin, toward the dressing
Use caution to avoid tension on any drains that are present. If the dressing is over a hairy area, remove in the direction of hair
growth. Tape should be pulled parallel to the skin, in a direction toward the dressing to avoid pulling on the suture line. Remove
dressings one layer at a time, observing appearance and drainage with clean gloves.
13. The nurse is caring for a client with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that
apply.)
A. Place moist sterile gauze over the site
B. Place the client supine
C. Contact the surgical team
D. Allow the client to have clear liquids
The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical emergency. Immediately
place the client supine, place damp sterile gauze over the site, contact the surgical team, do not allow the client anything by
mouth (NPO), observe for signs and symptoms of shock, and prepare the client for emergency surgery.
14. When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?
A. A pressure ulcer that extends through the fascia to muscle
B. A pressure ulcer that does not extend through the fascia
C. A pressure ulcer that involves only the epidermis
D. A pressure ulcer with bone exposure
Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to
muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve
exposure of muscle, bone, or connective tissue. Stage 2 ulcers are partial-thickness involving epidermis and/or dermis.
15. The nurse is caring for a client with a deep wound that requires packing. Which of the following is the correct technique for
wound packing?
A. Pack the wound tightly to prevent bleeding
B. Loosely pack the wound to allow for drainage
C. Pack the wound only to the surface level
D. Use dry gauze to pack the wound
Wounds should be loosely packed to allow for drainage and to prevent trauma to granulation tissue. Tight packing can cause
tissue damage and impede healing. The packing should fill the wound space but not be tightly compressed, allowing wound fluid
to be absorbed and drainage to escape.
16. The nurse is assessing a wound and notes the presence of eschar. The nurse should document this finding as:
A. Healthy granulation tissue
