NSG 3100 Skin & Wound NCLEX Questions & KEY
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse knows which description would be classified as a closed wound?
A. A large bruise on the side of the face
B. A surgical incision that is sutured closed
C. A puncture wound that is healing
D. An abrasion on the leg
____ 2. The nurse is educating the patient about the signs and symptoms of a wound infection. Which
statement indicates a need for further education?
A. “The wound will be red.”
B. “The wound will have pus.”
C. “The wound will be warm.”
D. “The wound will need to be treated.”
____ 3. The nurse identifies which type of wounds heals by tertiary intention?
A. An acute wound in which the patient has sutures placed when it happened
B. A pressure injury that was treated with dressing changes and is healed
C. An acute wound in which surgical glue was used to close the wound
D. A wound that was left open initially and closed later with sutures
____ 4. The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the
patient complains of a “popping sensation” and a wetness in the dressing, the nurse immediately
suspects which complication?
A. A wound infection
B. The stitches came loose
C. Wound dehiscence
D. Fistula formation
____ 5. The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has
completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon,
what should the nurse do?
A. Cover the wound with a sterile gauze pad.
B. Cover the wound with a transparent dressing.
C. Put pressure on the wound with a sterile gauze pad.
D. Cover the wound with gauze soaked with normal saline.
____ 6. The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure
injury who has a nursing diagnosis of impaired skin integrity?
A. Wound will be completely healed in 72 hours.
B. Wound will show signs of healing within 2 weeks.
C. Patient will develop no new pressure injuries.
D. Patient will ambulate twice a day.
, ____ 7. A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new
nurse causes the preceptor to intervene?
A. The nurse asks the UAP to assess the wound.
B. The nurse asks the UAP to report increased wound drainage.
C. The nurse asks the UAP to observe changes in dietary intake.
D. The nurse asks the UAP to change the dressing.
____ 8. The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk
for pressure injuries, the nurse should place the head of the bed in which position?
A. Flat
B. 90 degrees
C. 30 degrees
D. 45 degrees
____ 9. The nurse recognizes which intervention is not a form of mechanical debridement?
A. Wet to dry dressings
B. Whirlpool baths
C. Wet to damp dressing
D. Enzymatic dressing
____ 10. 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 are used for autolytic debridement.”
B. “Hydrocolloids are a type of occlusive dressing.”
C. “Occlusive dressings can be used on infected wounds.”
D. “Occlusive dressings support the most comfortable form of debridement.”
____ 11. The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?
A. A wound with a large amount of drainage
B. A wound that is tunneling
C. A postsurgical incision with staples
D. A wound with a moderate amount of drainage
____ 12. When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?
A. The drain must be compressed after emptying to work properly.
B. The drain must be connected to suction if ordered.
C. The drain is not sutured in place so care is taken to not dislodge it.
D. The suction pulls drainage away from the wound as it re-expands.
____ 13. The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by
the patient indicates the need for further education?
A. “I should fill my ice bag 2/3 full of ice.”
B. “I should use distilled water in my Aqua-K pad.”
C. “I can warm up my hot pack in the microwave.”
D. “I should check the order for how long to leave the compress on.”
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse knows which description would be classified as a closed wound?
A. A large bruise on the side of the face
B. A surgical incision that is sutured closed
C. A puncture wound that is healing
D. An abrasion on the leg
____ 2. The nurse is educating the patient about the signs and symptoms of a wound infection. Which
statement indicates a need for further education?
A. “The wound will be red.”
B. “The wound will have pus.”
C. “The wound will be warm.”
D. “The wound will need to be treated.”
____ 3. The nurse identifies which type of wounds heals by tertiary intention?
A. An acute wound in which the patient has sutures placed when it happened
B. A pressure injury that was treated with dressing changes and is healed
C. An acute wound in which surgical glue was used to close the wound
D. A wound that was left open initially and closed later with sutures
____ 4. The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the
patient complains of a “popping sensation” and a wetness in the dressing, the nurse immediately
suspects which complication?
A. A wound infection
B. The stitches came loose
C. Wound dehiscence
D. Fistula formation
____ 5. The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has
completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon,
what should the nurse do?
A. Cover the wound with a sterile gauze pad.
B. Cover the wound with a transparent dressing.
C. Put pressure on the wound with a sterile gauze pad.
D. Cover the wound with gauze soaked with normal saline.
____ 6. The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure
injury who has a nursing diagnosis of impaired skin integrity?
A. Wound will be completely healed in 72 hours.
B. Wound will show signs of healing within 2 weeks.
C. Patient will develop no new pressure injuries.
D. Patient will ambulate twice a day.
, ____ 7. A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new
nurse causes the preceptor to intervene?
A. The nurse asks the UAP to assess the wound.
B. The nurse asks the UAP to report increased wound drainage.
C. The nurse asks the UAP to observe changes in dietary intake.
D. The nurse asks the UAP to change the dressing.
____ 8. The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk
for pressure injuries, the nurse should place the head of the bed in which position?
A. Flat
B. 90 degrees
C. 30 degrees
D. 45 degrees
____ 9. The nurse recognizes which intervention is not a form of mechanical debridement?
A. Wet to dry dressings
B. Whirlpool baths
C. Wet to damp dressing
D. Enzymatic dressing
____ 10. 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 are used for autolytic debridement.”
B. “Hydrocolloids are a type of occlusive dressing.”
C. “Occlusive dressings can be used on infected wounds.”
D. “Occlusive dressings support the most comfortable form of debridement.”
____ 11. The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?
A. A wound with a large amount of drainage
B. A wound that is tunneling
C. A postsurgical incision with staples
D. A wound with a moderate amount of drainage
____ 12. When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?
A. The drain must be compressed after emptying to work properly.
B. The drain must be connected to suction if ordered.
C. The drain is not sutured in place so care is taken to not dislodge it.
D. The suction pulls drainage away from the wound as it re-expands.
____ 13. The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by
the patient indicates the need for further education?
A. “I should fill my ice bag 2/3 full of ice.”
B. “I should use distilled water in my Aqua-K pad.”
C. “I can warm up my hot pack in the microwave.”
D. “I should check the order for how long to leave the compress on.”
