LVN Wound Care & Dressing Techniques 3 — Questions and Answers
Question 1: A patient's wound is classified as having 'yellow slough' in the wound bed. What does this indicate about wound healing status?
- The wound is in the remodeling phase
- Necrotic tissue is present and may impede healing (Correct answer)
- Granulation tissue is beginning to form
- The wound has a pseudomonas infection
Correct answer: Necrotic tissue is present and may impede healing
Yellow slough is devitalized, necrotic tissue that creates a bacterial growth medium and must be removed to allow healing to progress.
Question 2: When using the RED-YELLOW-BLACK (RYB) wound assessment system, a wound with a black wound bed should be managed by:
- Applying a moisture-retentive dressing to promote autolysis (Correct answer)
- Irrigating daily and covering with gauze
- Using negative pressure wound therapy immediately
- Packing with iodoform gauze and leaving in place 5 days
Correct answer: Applying a moisture-retentive dressing to promote autolysis
Black wounds contain eschar that should be debrided; moisture-retentive dressings promote autolytic debridement of the necrotic tissue.
Question 3: Which action by the LVN demonstrates correct technique when removing an adherent dressing?
- Pull the dressing quickly away from the wound in one motion
- Soak the dressing with normal saline before removal to loosen adherence (Correct answer)
- Remove the dressing dry to assess wound drainage accurately
- Wear clean gloves only, as sterile technique is not needed for removal
Correct answer: Soak the dressing with normal saline before removal to loosen adherence
Moistening an adherent dressing with saline loosens it and prevents trauma to fragile wound tissue during removal.
Question 4: A nurse notes that a surgical wound has separated along the suture line with intestines visible through the opening. This is termed:
- Dehiscence
- Evisceration (Correct answer)
- Fistula formation
- Tunneling
Correct answer: Evisceration
Evisceration is the protrusion of internal organs through a wound opening and requires emergency intervention.
Question 5: A patient has a surgical wound with a Jackson-Pratt (JP) drain. The LVN notes the drain bulb is fully expanded and not compressed. What action should be taken?
- Document the finding and continue monitoring
- Notify the provider immediately
- Empty and recompress the bulb to restore suction (Correct answer)
- Remove the drain as it is no longer functioning
Correct answer: Empty and recompress the bulb to restore suction
A JP drain bulb must be emptied and recompressed to restore the negative pressure suction that removes wound drainage.
Question 6: Which patient population is at HIGHEST risk for developing a wound infection after a surgical procedure?
- A 25-year-old with an appendectomy who is ambulatory
- A 70-year-old diabetic with a BMI of 38 receiving corticosteroids (Correct answer)
- A 45-year-old non-smoker undergoing elective knee replacement
- A 30-year-old with no comorbidities having a cesarean section
Correct answer: A 70-year-old diabetic with a BMI of 38 receiving corticosteroids
Older age, diabetes, obesity, and immunosuppressant use each independently increase surgical site infection risk; this patient has all four.
Question 7: An LVN is documenting wound measurements. The wound measures 4 cm long, 2 cm wide, and 1.5 cm deep. How should this be documented in standard format?
- 2 cm × 4 cm × 1.5 cm (W × L × D)
- 4 cm × 2 cm × 1.5 cm (L × W × D) (Correct answer)
- 1.5 cm × 4 cm × 2 cm (D × L × W)
- 4 cm × 1.5 cm × 2 cm (L × D × W)
Correct answer: 4 cm × 2 cm × 1.5 cm (L × W × D)
Standard wound measurement documentation follows the format length × width × depth (L × W × D).
LVN Wound Care & Dressing Techniques 3
A patient's wound is classified as having 'yellow slough' in the wound bed.
What does this indicate about wound healing status?