NCLEX-PN Test #13 1 — Questions and Answers
Question 1: A nurse assesses a pressure injury with full-thickness skin loss, visible subcutaneous fat, and no exposed bone or tendon. How should this wound be staged?
- Stage I
- Stage II
- Stage III (Correct answer)
- Stage IV
Correct answer: Stage III
A Stage III pressure injury involves full-thickness skin loss with visible subcutaneous fat but without exposed bone, tendon, or muscle. Stage IV would involve exposed bone, tendon, or muscle.
Question 2: A nurse is performing a wet-to-dry dressing change on a wound with necrotic tissue. What is the primary purpose of this dressing technique?
- Promote autolytic debridement
- Provide mechanical debridement (Correct answer)
- Keep the wound moist to support granulation
- Reduce wound odor
Correct answer: Provide mechanical debridement
Wet-to-dry dressings provide mechanical debridement: the dressing is moistened, placed in the wound, and as it dries it adheres to necrotic tissue. When removed, the dead tissue is pulled away. This technique is non-selective and may also remove healthy tissue.
Question 3: While performing a dressing change, a nurse observes bright red blood suddenly saturating the wound dressing. What is the priority nursing action?
- Remove the dressing and irrigate the wound
- Apply direct pressure and call for immediate assistance (Correct answer)
- Document the finding and notify the physician at next rounds
- Elevate the affected extremity and continue the dressing change
Correct answer: Apply direct pressure and call for immediate assistance
Bright red blood indicates arterial bleeding, which is a hemorrhagic emergency. The nurse should apply direct pressure immediately to control bleeding and call for help. Removing the dressing would remove the tamponade effect and worsen bleeding.
Question 4: A nurse is irrigating a deep wound with normal saline. Which action reflects proper wound irrigation technique?
- Use a dry cotton swab to remove debris before irrigation
- Direct the irrigation stream from the dirtiest to cleanest area
- Use a 35 mL syringe with an 18-gauge angiocatheter to deliver fluid at 8–15 psi (Correct answer)
- Fill the wound basin and allow fluid to soak for 10 minutes
Correct answer: Use a 35 mL syringe with an 18-gauge angiocatheter to deliver fluid at 8–15 psi
Effective wound irrigation uses a 35 mL syringe with an 18-gauge angiocatheter to deliver saline at 8–15 psi — sufficient pressure to remove debris without traumatizing wound tissue. Irrigation should proceed from the cleanest to the dirtiest area.
Question 5: A patient's surgical wound edges are separated with visible subcutaneous tissue. The nurse identifies this as wound dehiscence. What is the immediate nursing action?
- Apply a dry sterile dressing and document
- Irrigate the wound with povidone-iodine and reapply the original dressing
- Cover the wound with a sterile saline-moistened dressing and notify the surgeon immediately (Correct answer)
- Ask the patient to apply pressure to the wound edges and call the charge nurse
Correct answer: Cover the wound with a sterile saline-moistened dressing and notify the surgeon immediately
Wound dehiscence requires immediate intervention. The nurse should cover the wound with a sterile saline-moistened dressing to keep exposed tissue moist and prevent infection, then notify the surgeon immediately. The patient should be placed in low Fowler's position with knees slightly flexed to reduce tension on the wound.
Question 6: A nurse is caring for a patient with a venous stasis ulcer on the lower leg. Which intervention is most important to include in the plan of care?
- Keep the leg in a dependent position to improve circulation
- Apply compression therapy as prescribed (Correct answer)
- Use only dry dressings to prevent maceration
- Restrict ambulation to prevent further skin breakdown
Correct answer: Apply compression therapy as prescribed
Compression therapy is the cornerstone of venous stasis ulcer treatment. It counteracts venous hypertension, reduces edema, and promotes venous return to facilitate healing. Leg elevation when resting also assists. Dependent positioning would worsen venous stasis.
NCLEX-PN Test #13 1
A nurse assesses a pressure injury with full-thickness skin loss, visible subcutaneous fat, and no exposed bone or tendon.
How should this wound be staged?