LPN Wound Care and Pressure Injury Staging 5 — Questions and Answers
Question 1: An LPN is caring for a patient with a venous leg ulcer. Which characteristic BEST distinguishes it from an arterial ulcer?
- Located on the lateral malleolus with minimal exudate and dry wound bed
- Painful at rest, with a pale wound bed and absent pedal pulses
- Located on the medial gaiter area with moderate-to-heavy exudate (Correct answer)
- Deep, punched-out appearance with necrotic base and black eschar
Correct answer: Located on the medial gaiter area with moderate-to-heavy exudate
Venous ulcers classically appear on the medial gaiter (lower leg/ankle) with moderate-to-heavy exudate due to venous insufficiency.
Question 2: Which intervention BEST prevents friction injuries during patient repositioning?
- Using a lift sheet or slide board to move the patient (Correct answer)
- Pulling the patient across the bed sheet by grasping the gown
- Placing a wet cloth under the patient to reduce resistance
- Having the patient assist by pushing with their elbows
Correct answer: Using a lift sheet or slide board to move the patient
Using a lift sheet or slide board prevents the skin from dragging across surfaces, eliminating friction and shear forces.
Question 3: A patient's wound culture grows Pseudomonas aeruginosa. Which wound characteristic is MOST associated with this organism?
- White, cottage-cheese-like exudate
- Blue-green exudate with a fruity odor (Correct answer)
- Thick, brown, malodorous drainage
- Thin, serous, yellow-tinged drainage
Correct answer: Blue-green exudate with a fruity odor
Pseudomonas aeruginosa infection classically produces blue-green pigmented exudate with a characteristic fruity or grape-like odor.
Question 4: Which action should the LPN take FIRST upon discovering a patient lying on a pressure injury site?
- Document the wound and continue routine care
- Reposition the patient to offload pressure from the wound (Correct answer)
- Apply a wet-to-dry dressing to the wound immediately
- Increase the patient's fluid intake
Correct answer: Reposition the patient to offload pressure from the wound
Relieving pressure is the immediate priority to prevent further tissue ischemia and injury.
Question 5: A Braden Scale score of 16 indicates which level of pressure injury risk?
- No risk
- Mild risk (Correct answer)
- Moderate risk
- High risk
Correct answer: Mild risk
A Braden score of 15–16 indicates mild risk for pressure injury development; scores ≤9 indicate very high risk.
Question 6: When teaching a patient with a new colostomy about peristomal skin care, which instruction is MOST important for preventing skin breakdown?
- Clean the skin with alcohol wipes before applying the pouch
- Ensure the pouch opening is cut 1 inch larger than the stoma
- Cut the pouch opening to fit within 1/8 inch of the stoma base (Correct answer)
- Change the pouch system every 24 hours regardless of leakage
Correct answer: Cut the pouch opening to fit within 1/8 inch of the stoma base
Cutting the opening to within 1/8 inch of the stoma prevents stool from contacting peristomal skin, the leading cause of skin breakdown.
Question 7: Which finding indicates that a wound is NOT progressing toward healing and requires reassessment of the care plan?
- Decrease in wound size over 2 weeks
- Increase in granulation tissue visible in the wound bed
- Increase in wound size or depth after 2 weeks of treatment (Correct answer)
- Wound exudate changing from purulent to serous
Correct answer: Increase in wound size or depth after 2 weeks of treatment
A wound that increases in size or depth after two weeks of appropriate treatment indicates treatment failure and requires care plan revision.
LPN Wound Care and Pressure Injury Staging 5
An LPN is caring for a patient with a venous leg ulcer.
Which characteristic BEST distinguishes it from an arterial ulcer?