LVN Wound Care 2 — Questions and Answers
Question 1: A Stage II pressure injury is best characterized by which finding?
- Full-thickness skin loss exposing subcutaneous tissue
- Partial-thickness skin loss with a shallow open bed or intact blister (Correct answer)
- Intact skin with non-blanchable erythema
- Full-thickness tissue loss with exposed bone or tendon
Correct answer: Partial-thickness skin loss with a shallow open bed or intact blister
Stage II pressure injuries involve partial-thickness skin loss presenting as a shallow open wound or intact/ruptured serum-filled blister.
Question 2: When documenting a wound, the LVN notes the wound edges are 'undermined.' What does this mean?
- The wound edges are raised above the wound bed
- Tissue destruction extends under intact skin beyond the wound margins (Correct answer)
- The wound edges are macerated from excess moisture
- The wound has two distinct drainage channels
Correct answer: Tissue destruction extends under intact skin beyond the wound margins
Undermining refers to tissue destruction that extends under the surrounding intact skin, creating a pocket around the wound edge.
Question 3: Which type of wound exudate suggests a high bacterial bioburden and potential infection?
- Serous — clear, watery
- Serosanguineous — pink-tinged
- Purulent — thick, opaque, green or yellow (Correct answer)
- Sanguineous — bright red
Correct answer: Purulent — thick, opaque, green or yellow
Purulent exudate (thick, yellow, green, or tan) indicates the presence of white blood cells and bacteria, signaling infection.
Question 4: The LVN is caring for a patient with a venous leg ulcer. Which characteristic finding differentiates it from an arterial ulcer?
- Deep crater with pale wound bed and absent pedal pulses
- Punched-out appearance located on the toe tips
- Shallow ulcer with irregular edges and brownish skin discoloration around it (Correct answer)
- Painful ulcer worsened by leg elevation
Correct answer: Shallow ulcer with irregular edges and brownish skin discoloration around it
Venous ulcers are typically shallow with irregular edges, located around the medial malleolus, and surrounded by hyperpigmented (brownish) skin.
Question 5: A patient's surgical wound is healing by secondary intention. What does this indicate?
- The wound edges were sutured together immediately after surgery
- The wound is left open and heals from the base up by granulation tissue (Correct answer)
- A skin graft was applied to close the wound
- The wound was closed with staples within 24 hours
Correct answer: The wound is left open and heals from the base up by granulation tissue
Secondary intention healing occurs when a wound is left open and fills in from the bottom up through granulation tissue formation.
Question 6: Which action is most appropriate when the LVN observes bright red drainage soaking through a post-operative dressing 1 hour after surgery?
- Remove the dressing and apply a new one
- Reinforce the dressing and notify the charge nurse or physician immediately (Correct answer)
- Document the finding and reassess in 2 hours
- Apply firm manual pressure and wait 30 minutes before reporting
Correct answer: Reinforce the dressing and notify the charge nurse or physician immediately
Bright red saturation of a dressing within the first hour post-op suggests hemorrhage; the dressing should be reinforced and the provider notified immediately.
Question 7: When measuring a wound for documentation, how should the LVN correctly record wound dimensions?
- Width × Depth only
- Length × Width × Depth (using clock positions: 12 o'clock = head) (Correct answer)
- Circumference and depth only
- Diameter measured at the widest point only
Correct answer: Length × Width × Depth (using clock positions: 12 o'clock = head)
Standard wound documentation uses length (head-to-toe, 12–6 o'clock) × width (side-to-side, 3–9 o'clock) × depth in centimeters.
LVN Wound Care 2
A Stage II pressure injury is best characterized by which finding?