Chapter 28: Wound Care
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse
should use a swab to clean:
a. from the outer abdomen toward the wound.
b. in a circular motion around the wound circling to the outside.
c. from the left to the right across the wound.
d. directly over the wound.
ANS: B
A circular motion around the wound toward the outside keeps the wound area
cleanest.
DIF: Cognitive Level: Application REF: m 774, Skill 38-1 OBJ:
Clinical Practice #1 TOP: Wound Cleaning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. A patient is due for a wound dressing change for a horizontal lower abdominal incision.
In which direction should the nurse pull to remove the tape from the old dressing?
a. From left to right across the abdomen
b. From right to left across the abdomen
c. From the top of the wound to the bottom
d. From each of the four sides toward the wound
ANS: D
The tape should be removed by pulling it off toward the wound. This helps prevent
disruption of the wound.
DIF: Cognitive Level: Application REF: m 774, Skill 38-1 OBJ:
Clinical Practice #1 TOP: Wound Care KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk potential
3. A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:
a. keep the wound dry.
b. help destroy microorganisms in an infected wound.
c. occlude air and promote breakdown of necrotic tissue.
d. leave the dressing in place for 10 days.
ANS: C
Hydrocolloid dressings are air-occlusive dressings used on noninfected wounds that
provide a moist environment for wound healing. They can be left in place for up to 7
days.
DIF: Cognitive Level: Comprehension REF: m 774 OBJ: Clinical
Practice #1 TOP: Hydrocolloid Dressing KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
, 4. The nurse changing a wet-to-damp normal saline dressing for a patient with an ulcer on
the heel finds that the old dressing is stuck to the wound bed. The nurses most beneficial
intervention would be to:
a. add normal saline to loosen it.
b. pull it off using slow, steady pressure.
c. leave it in place and cover it with new, wet dressings.
d. moisten it with povidone-iodine.
ANS: A
If the dressing sticks to the wound, normal saline should be added to loosen it. Pulling
loose a stuck dressing damages new tissue. Leaving it in place does not promote a
clean wound. Povidone-iodine must be ordered.
DIF: Cognitive Level: Analysis REF: m 779, Skill 38-3 OBJ:
Clinical Practice #3 TOP: Wet-to-Dry Dressings KEY: Nursing
Process Step: Implementation MSC: NCLEX: Physiological
Integrity: reduction of risk potential
5. A nurse performing a right eye irrigation will position the patient:
a. upright with the head hyperextended.
b. upright with the head tilted toward the left eye.
c. supine with the head hyperextended.
d. supine with the head tilted toward the right eye.
ANS: D
The patient should be positioned supine with the head tilted toward the affected eye.
This position allows the irrigation solution to drain away from the eye and not
contaminate the other eye.
DIF: Cognitive Level: Application REF: m 782, Steps 38-4 OBJ:
Clinical Practice #3 TOP: Eye Irrigations KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
6. A nurse removing wound staples would engage the staple puller and squeeze the handles
completely and:
a. pull to the right.
b. pull outward.
c. pull to the left.
d. rotate.
ANS: B
The handles should be squeezed together all the way. This depresses the center of the
staple and allows it to be lifted outward from the skin.
DIF: Cognitive Level: Application REF: m 781, Steps 38-3 OBJ:
Clinical Practice #4 TOP: Staple Removal KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
7. The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:
a. drawing the wound edges together by negative pressure.
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse
should use a swab to clean:
a. from the outer abdomen toward the wound.
b. in a circular motion around the wound circling to the outside.
c. from the left to the right across the wound.
d. directly over the wound.
ANS: B
A circular motion around the wound toward the outside keeps the wound area
cleanest.
DIF: Cognitive Level: Application REF: m 774, Skill 38-1 OBJ:
Clinical Practice #1 TOP: Wound Cleaning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. A patient is due for a wound dressing change for a horizontal lower abdominal incision.
In which direction should the nurse pull to remove the tape from the old dressing?
a. From left to right across the abdomen
b. From right to left across the abdomen
c. From the top of the wound to the bottom
d. From each of the four sides toward the wound
ANS: D
The tape should be removed by pulling it off toward the wound. This helps prevent
disruption of the wound.
DIF: Cognitive Level: Application REF: m 774, Skill 38-1 OBJ:
Clinical Practice #1 TOP: Wound Care KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk potential
3. A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:
a. keep the wound dry.
b. help destroy microorganisms in an infected wound.
c. occlude air and promote breakdown of necrotic tissue.
d. leave the dressing in place for 10 days.
ANS: C
Hydrocolloid dressings are air-occlusive dressings used on noninfected wounds that
provide a moist environment for wound healing. They can be left in place for up to 7
days.
DIF: Cognitive Level: Comprehension REF: m 774 OBJ: Clinical
Practice #1 TOP: Hydrocolloid Dressing KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
, 4. The nurse changing a wet-to-damp normal saline dressing for a patient with an ulcer on
the heel finds that the old dressing is stuck to the wound bed. The nurses most beneficial
intervention would be to:
a. add normal saline to loosen it.
b. pull it off using slow, steady pressure.
c. leave it in place and cover it with new, wet dressings.
d. moisten it with povidone-iodine.
ANS: A
If the dressing sticks to the wound, normal saline should be added to loosen it. Pulling
loose a stuck dressing damages new tissue. Leaving it in place does not promote a
clean wound. Povidone-iodine must be ordered.
DIF: Cognitive Level: Analysis REF: m 779, Skill 38-3 OBJ:
Clinical Practice #3 TOP: Wet-to-Dry Dressings KEY: Nursing
Process Step: Implementation MSC: NCLEX: Physiological
Integrity: reduction of risk potential
5. A nurse performing a right eye irrigation will position the patient:
a. upright with the head hyperextended.
b. upright with the head tilted toward the left eye.
c. supine with the head hyperextended.
d. supine with the head tilted toward the right eye.
ANS: D
The patient should be positioned supine with the head tilted toward the affected eye.
This position allows the irrigation solution to drain away from the eye and not
contaminate the other eye.
DIF: Cognitive Level: Application REF: m 782, Steps 38-4 OBJ:
Clinical Practice #3 TOP: Eye Irrigations KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
6. A nurse removing wound staples would engage the staple puller and squeeze the handles
completely and:
a. pull to the right.
b. pull outward.
c. pull to the left.
d. rotate.
ANS: B
The handles should be squeezed together all the way. This depresses the center of the
staple and allows it to be lifted outward from the skin.
DIF: Cognitive Level: Application REF: m 781, Steps 38-3 OBJ:
Clinical Practice #4 TOP: Staple Removal KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
7. The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:
a. drawing the wound edges together by negative pressure.
