Sample Questions and Answers
Question 1: A patient with limited mobility has a non-blanchable area of redness over the sacrum. According to current pressure injury staging guidelines, how should the nurse classify this wound?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue pressure injury
D. Unstageable pressure injury
Answer: A. Stage 1 pressure injury
Explanation: A Stage 1 pressure injury is characterized by intact skin with localized, non-blanchable erythema over a bony prominence. Early identification is critical because prompt intervention can prevent further tissue damage and progression to more severe stages. The nurse should immediately implement pressure redistribution strategies, reposition the patient regularly, assess nutritional status, and monitor skin integrity closely. Patient and caregiver education regarding pressure injury prevention is equally important. Recognizing Stage 1 injuries early allows healthcare providers to initiate evidence-based interventions that promote tissue recovery, improve patient comfort, and reduce the risk of complications associated with prolonged pressure.
Question 2: A patient with diabetes presents with a plantar foot ulcer. Which nursing intervention is most important for promoting wound healing?
A. Encourage the patient to continue walking without restrictions.
B. Implement appropriate offloading techniques to reduce pressure on the affected foot.
C. Apply heat directly to the wound.
D. Leave the wound exposed to air throughout the day.
Answer: B. Implement appropriate offloading techniques to reduce pressure on the affected foot.
Explanation: Offloading is one of the most effective interventions for healing diabetic foot ulcers because it reduces continuous pressure and mechanical stress on the wound. Appropriate offloading devices, specialized footwear, or total contact casting help redistribute weight and create an environment that supports tissue repair. Nurses should also monitor blood glucose control, assess for signs of infection, educate patients on daily foot care, and encourage adherence to the treatment plan. Combining pressure relief with comprehensive wound management significantly improves healing outcomes while reducing the risk of infection, hospitalization, and lower-extremity amputation.
Question 3: During a wound assessment, the nurse observes thick yellow tissue covering part of the wound bed. How should this tissue be identified?
A. Granulation tissue
B. Eschar
C. Slough
D. Epithelial tissue
Answer: C. Slough
Explanation: Slough is non-viable tissue that commonly appears yellow, tan, or cream-colored and may be moist or stringy within the wound bed. Because slough can delay healing and increase the risk of bacterial growth, it should be assessed carefully as part of the overall wound management plan. Depending on the patient’s condition and wound characteristics, appropriate debridement methods may be considered to remove non-viable tissue and promote healthy granulation. Accurate wound assessment enables nurses to select appropriate interventions, monitor healing progress, and support evidence-based wound care practices that improve patient outcomes.
Question 4: Which patient factor is most likely to delay wound healing?
A. Adequate protein intake
B. Controlled blood glucose levels
C. Poor nutritional status and uncontrolled diabetes
D. Regular repositioning and pressure relief
Answer: C. Poor nutritional status and uncontrolled diabetes
Explanation: Wound healing is influenced by many systemic factors, including nutrition, circulation, infection, and chronic disease management. Poor nutrition limits the body’s ability to produce collagen and repair damaged tissue, while uncontrolled diabetes impairs circulation, decreases immune function, and slows the healing process. Nurses should evaluate nutritional intake, encourage blood glucose management, monitor for signs of infection, and collaborate with dietitians and other healthcare professionals when necessary. Addressing these underlying factors improves wound healing, reduces complications, and supports successful long-term patient recovery.
Question 5: Which nursing action best helps reduce the risk of wound infection during dressing changes?
A. Perform dressing changes using clean or sterile technique according to clinical guidelines.
B. Reuse dressing supplies whenever possible.
C. Delay dressing changes until visible drainage appears.
D. Touch the wound bed with ungloved hands during assessment.
Answer: A. Perform dressing changes using clean or sterile technique according to clinical guidelines.
Explanation: Infection prevention is a fundamental principle of wound care. Following appropriate clean or sterile technique, depending on the clinical setting and wound type, helps minimize contamination and reduces the risk of infection. Nurses should perform proper hand hygiene, use appropriate personal protective equipment, assess the wound during each dressing change, and dispose of contaminated materials safely. Patient education regarding wound care at home is also important for preventing infection after discharge. Consistent adherence to infection prevention practices promotes optimal healing, protects patient safety, and supports positive clinical outcomes.
Question 6: A nurse is assessing a patient with a venous leg ulcer. Which assessment finding is most commonly associated with this type of wound?
A. Pale wound bed with minimal drainage and severe pain when the leg is elevated
B. Irregular wound edges with moderate to heavy drainage around the lower leg or ankle
C. Dry black eschar on the toes caused by poor arterial circulation
D. Circular wound over a pressure point with exposed bone
Answer: B. Irregular wound edges with moderate to heavy drainage around the lower leg or ankle
Explanation: Venous leg ulcers typically develop around the medial lower leg or ankle due to chronic venous insufficiency. They often have irregular borders, moderate to heavy drainage, surrounding edema, and skin discoloration caused by poor venous return. Nurses should assess circulation, monitor for signs of infection, encourage leg elevation when appropriate, and support prescribed compression therapy if arterial circulation is adequate. Understanding the characteristics of different wound types helps clinicians develop individualized treatment plans, improve healing outcomes, reduce recurrence, and educate patients about long-term prevention strategies.
Question 7: During a wound assessment, which finding most strongly suggests that a wound is progressing toward normal healing?
A. Increasing wound size and surrounding redness
B. Healthy red granulation tissue filling the wound bed
C. Thick black tissue covering the entire wound surface
D. Persistent foul odor with increased drainage
Answer: B. Healthy red granulation tissue filling the wound bed
Explanation: Granulation tissue is a positive indicator of wound healing. It appears as moist, healthy red tissue composed of new capillaries, collagen, and connective tissue that gradually fills the wound during the proliferative phase of healing. Nurses should continue protecting this fragile tissue by maintaining an appropriate moisture balance, selecting suitable dressings, preventing infection, and minimizing trauma during dressing changes. Ongoing assessment of wound size, tissue appearance, drainage, and surrounding skin helps determine whether the wound is healing as expected and whether modifications to the treatment plan are needed.
Question 8: Which nursing intervention best supports moisture balance during wound management?
A. Allow the wound to dry completely between dressing changes.
B. Select an appropriate dressing that maintains a moist wound environment while controlling excess drainage.
C. Clean the wound repeatedly with strong antiseptic solutions.
D. Leave the wound uncovered whenever possible.
Answer: B. Select an appropriate dressing that maintains a moist wound environment while controlling excess drainage.
Explanation: Maintaining an optimal moisture balance is a key principle of evidence-based wound care. A moist wound environment promotes cell migration, supports tissue repair, reduces pain during dressing changes, and encourages faster healing. However, excessive moisture can damage surrounding skin, while an overly dry wound may delay tissue regeneration. Nurses should evaluate the amount of drainage, wound depth, and surrounding skin condition when selecting dressings. Appropriate dressing selection helps create ideal healing conditions while protecting healthy tissue and reducing the risk of wound-related complications.
Question 9: A patient asks why good nutrition is important during wound healing. Which response by the nurse is most appropriate?
A. Nutrition has very little effect on wound healing.
B. Adequate protein, calories, vitamins, and minerals help the body repair damaged tissue and support immune function.
C. Only fluid intake affects wound healing.
D. Nutritional needs remain unchanged regardless of wound severity.
Answer: B. Adequate protein, calories, vitamins, and minerals help the body repair damaged tissue and support immune function.
Explanation: Proper nutrition provides the building blocks necessary for tissue repair, collagen production, immune function, and overall recovery. Patients with chronic wounds often require increased protein and adequate calorie intake to support healing. Vitamins such as A and C, along with minerals like zinc, also contribute to tissue regeneration and immune defense. Nurses should assess nutritional status, identify patients at risk for malnutrition, collaborate with dietitians when appropriate, and educate patients about healthy dietary choices. Optimizing nutrition can significantly improve wound healing and reduce recovery time.
Question 10: Which nursing responsibility is most important when documenting wound care?
A. Recording only the dressing that was applied.
B. Accurately documenting wound size, appearance, drainage, interventions, and the patient’s response to treatment.
C. Waiting until discharge to complete wound documentation.
D. Estimating wound measurements without performing an assessment.
Answer: B. Accurately documenting wound size, appearance, drainage, interventions, and the patient’s response to treatment.
Explanation: Comprehensive wound documentation supports continuity of care, evaluates treatment effectiveness, and provides an accurate legal and clinical record. Nurses should consistently record wound measurements, tissue characteristics, drainage amount and type, condition of the surrounding skin, pain level, interventions performed, and the patient’s response to treatment. Consistent documentation allows healthcare providers to monitor healing progress, identify complications early, communicate effectively with the interdisciplinary team, and adjust the care plan when necessary. Accurate records are essential for delivering safe, evidence-based wound management and improving patient outcomes.
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