LPN Wound Care and Pressure Injury Staging 4 — Questions and Answers
Question 1: Which of the following patients has the HIGHEST risk for developing a pressure injury?
- A 30-year-old ambulatory patient with a minor laceration
- A 75-year-old incontinent patient on bedrest with a Braden score of 12 (Correct answer)
- A 55-year-old diabetic patient who walks independently
- A 45-year-old patient post-appendectomy, mobile day 1
Correct answer: A 75-year-old incontinent patient on bedrest with a Braden score of 12
A low Braden score (≤12), incontinence, advanced age, and immobility combine to place this patient at very high risk.
Question 2: A patient's wound shows bright red, moist, granular tissue filling the wound bed. This indicates:
- Infected wound tissue
- Necrotic tissue requiring debridement
- Healthy granulation tissue (Correct answer)
- Wound dehiscence
Correct answer: Healthy granulation tissue
Bright red, moist, beefy-appearing granular tissue is healthy granulation tissue, indicating the wound is progressing toward healing.
Question 3: Which action by an LPN demonstrates correct technique when irrigating a wound?
- Using a bulb syringe with high pressure to dislodge debris
- Irrigating with normal saline using a 19-gauge angiocath at 8–15 psi (Correct answer)
- Using hydrogen peroxide to kill bacteria in the wound
- Packing the wound tightly with dry gauze after irrigation
Correct answer: Irrigating with normal saline using a 19-gauge angiocath at 8–15 psi
Wound irrigation should deliver 8–15 psi using normal saline with an appropriate syringe-and-angiocath combination to cleanse without damaging tissue.
Question 4: A stage 4 pressure injury exposes bone and tendon. Which dressing characteristic is MOST important for this wound?
- Maintaining a moist wound environment (Correct answer)
- Providing complete occlusion to prevent any gas exchange
- Using a dry dressing to absorb maximum exudate
- Applying silver-containing dressings regardless of infection signs
Correct answer: Maintaining a moist wound environment
Maintaining a moist wound environment is essential for promoting granulation and epithelialization in deep wounds like stage 4 injuries.
Question 5: A patient with diabetes has a neuropathic foot ulcer. Which assessment finding is MOST characteristic of diabetic neuropathic ulcers?
- Occurs over pressure points on the plantar surface with minimal pain (Correct answer)
- Occurs on the lateral malleolus with severe pain
- Located on the gaiter area with surrounding hemosiderin staining
- Located on the fingertips with ragged wound edges
Correct answer: Occurs over pressure points on the plantar surface with minimal pain
Diabetic neuropathic ulcers typically occur on pressure points of the plantar foot and are painless due to sensory neuropathy.
Question 6: When using the clock method to document wound tunneling, 12 o'clock corresponds to which direction?
- The patient's left side
- Toward the patient's feet
- Toward the patient's head (Correct answer)
- The patient's right side
Correct answer: Toward the patient's head
In wound clock documentation, 12 o'clock is always oriented toward the patient's head regardless of wound location.
Question 7: Which finding in a healing surgical wound should the LPN report to the charge nurse IMMEDIATELY?
- Mild serous drainage on postoperative day 2
- Wound edges well approximated with no redness
- Separation of wound edges with visible subcutaneous tissue (Correct answer)
- Slight swelling around the incision on day 1
Correct answer: Separation of wound edges with visible subcutaneous tissue
Wound dehiscence — separation of wound edges exposing underlying tissue — is an emergency requiring immediate notification and intervention.
LPN Wound Care and Pressure Injury Staging 4
Which of the following patients has the HIGHEST risk for developing a pressure injury?