AMSN Wound Care and Skin Integrity 2 — Questions and Answers
Question 1: A postoperative patient's abdominal wound has separated with the bowel protruding through the incision. The nurse's immediate action is:
- Apply a sterile dry dressing and call the provider
- Cover the wound with moist sterile saline gauze, keep the patient supine with knees flexed, and call the provider STAT (Correct answer)
- Push the bowel back into the wound and apply pressure
- Irrigate the wound with saline and apply an occlusive dressing
Correct answer: Cover the wound with moist sterile saline gauze, keep the patient supine with knees flexed, and call the provider STAT
Evisceration requires covering exposed bowel with moist sterile saline gauze to prevent drying, keeping the patient still, and calling the surgical team for emergency closure.
Question 2: A patient with a venous stasis ulcer on the lower leg is prescribed compression therapy. The nurse should apply compression wraps:
- With the greatest pressure at the knee and decreasing distally
- With the greatest pressure at the ankle and decreasing toward the knee (graduated compression)
- Only during sleep to reduce discomfort
- After assessing for arterial insufficiency — do not apply if ABIs are below 0.5 (Correct answer)
Correct answer: After assessing for arterial insufficiency — do not apply if ABIs are below 0.5
Compression is contraindicated in severe arterial disease (ABI <0.5); assessing ankle-brachial index (ABI) before applying compression prevents dangerous ischemia.
Question 3: A patient has a wound with red, moist, granulating tissue filling the wound bed. The nurse correctly identifies this as:
- A sign of wound infection requiring cultures
- Healthy granulation tissue indicating the wound is healing (Correct answer)
- Necrotic tissue requiring debridement
- Eschar that should be monitored
Correct answer: Healthy granulation tissue indicating the wound is healing
Bright red, moist, granulating tissue is healthy new tissue forming during the proliferative phase of wound healing.
Question 4: Which Braden Scale score indicates the HIGHEST risk for pressure injury development?
- 23
- 18
- 13
- 6 (Correct answer)
Correct answer: 6
The Braden Scale scores from 6 (lowest possible) to 23 (no risk); a score of 6 indicates the most severe risk for pressure injury across all subscales.
Question 5: A nurse is debriding a wound using wet-to-dry dressing changes. The nurse understands this method works by:
- Promoting autolysis through moisture balance
- Mechanically removing necrotic tissue as the gauze dries and adheres to the wound (Correct answer)
- Applying enzymatic agents to break down necrosis
- Providing a moist wound environment for healing
Correct answer: Mechanically removing necrotic tissue as the gauze dries and adheres to the wound
Wet-to-dry debridement works mechanically — the moist gauze dries and adheres to necrotic tissue, which is removed when the dressing is changed.
Question 6: A patient with a surgical wound develops dehiscence (wound separation without organ protrusion). The nurse should:
- Irrigate with hydrogen peroxide and close with butterfly strips
- Cover with a sterile dressing, notify the provider, and have the patient avoid Valsalva maneuver (Correct answer)
- Place the patient in Trendelenburg position and apply pressure
- Apply a wound closure device immediately without notifying the provider
Correct answer: Cover with a sterile dressing, notify the provider, and have the patient avoid Valsalva maneuver
Wound dehiscence requires sterile wound coverage, provider notification for possible surgical re-closure, and preventing increased intra-abdominal pressure.
AMSN Wound Care and Skin Integrity 2
A postoperative patient's abdominal wound has separated with the bowel protruding through the incision.
The nurse's immediate action is: