LVN Wound Care 2

Question 1

A Stage II pressure injury is best characterized by which finding?

Accepted Answer

Partial-thickness skin loss with a shallow open bed or intact blister

Answer

Full-thickness skin loss exposing subcutaneous tissue

Answer

Intact skin with non-blanchable erythema

Answer

Full-thickness tissue loss with exposed bone or tendon

Question 2

When documenting a wound, the LVN notes the wound edges are 'undermined.' What does this mean?

Accepted Answer

Tissue destruction extends under intact skin beyond the wound margins

Answer

The wound edges are raised above the wound bed

Answer

The wound edges are macerated from excess moisture

Answer

The wound has two distinct drainage channels

Question 3

Which type of wound exudate suggests a high bacterial bioburden and potential infection?

Accepted Answer

Purulent — thick, opaque, green or yellow

Answer

Serous — clear, watery

Answer

Serosanguineous — pink-tinged

Answer

Sanguineous — bright red

Question 4

The LVN is caring for a patient with a venous leg ulcer. Which characteristic finding differentiates it from an arterial ulcer?

Accepted Answer

Shallow ulcer with irregular edges and brownish skin discoloration around it

Answer

Deep crater with pale wound bed and absent pedal pulses

Answer

Punched-out appearance located on the toe tips

Answer

Painful ulcer worsened by leg elevation

Question 5

A patient's surgical wound is healing by secondary intention. What does this indicate?

Accepted Answer

The wound is left open and heals from the base up by granulation tissue

Answer

The wound edges were sutured together immediately after surgery

Answer

A skin graft was applied to close the wound

Answer

The wound was closed with staples within 24 hours

Question 6

Which action is most appropriate when the LVN observes bright red drainage soaking through a post-operative dressing 1 hour after surgery?

Accepted Answer

Reinforce the dressing and notify the charge nurse or physician immediately

Answer

Remove the dressing and apply a new one

Answer

Document the finding and reassess in 2 hours

Answer

Apply firm manual pressure and wait 30 minutes before reporting

Question 7

When measuring a wound for documentation, how should the LVN correctly record wound dimensions?

Accepted Answer

Length × Width × Depth (using clock positions: 12 o'clock = head)

Answer

Width × Depth only

Answer

Circumference and depth only

Answer

Diameter measured at the widest point only