LVN Wound Care & Dressing Techniques 4 — Questions and Answers
Question 1: A patient with a sacral pressure injury receives negative pressure wound therapy (NPWT). Which finding requires the LVN to stop the therapy and notify the provider immediately?
- Wound drainage that is serosanguineous in color
- A visible blood vessel or untreated osteomyelitis in the wound (Correct answer)
- Mild periwound erythema at the foam border
- Wound depth has decreased since therapy began
Correct answer: A visible blood vessel or untreated osteomyelitis in the wound
NPWT is contraindicated when there is an exposed blood vessel or untreated osteomyelitis due to risk of hemorrhage or spreading bone infection.
Question 2: Which characteristic distinguishes a partial-thickness wound from a full-thickness wound?
- Partial-thickness wounds involve only the epidermis and possibly dermis (Correct answer)
- Partial-thickness wounds extend into subcutaneous tissue
- Partial-thickness wounds always require surgical closure
- Partial-thickness wounds take longer to heal than full-thickness wounds
Correct answer: Partial-thickness wounds involve only the epidermis and possibly dermis
Partial-thickness wounds involve the epidermis and possibly dermis and heal by re-epithelialization without granulation tissue.
Question 3: A patient's wound culture returns positive for Methicillin-resistant Staphylococcus aureus (MRSA). In addition to standard wound care, the LVN should initiate:
- Droplet precautions
- Airborne precautions
- Contact precautions (Correct answer)
- Reverse isolation
Correct answer: Contact precautions
MRSA is transmitted via direct contact, so contact precautions (gown and gloves) are required to prevent spread.
Question 4: When applying a hydrocolloid dressing, the LVN should leave a margin of at least how many centimeters of intact skin beyond the wound edge?
- 0.5 cm
- 1 cm
- 2.5 cm (Correct answer)
- 5 cm
Correct answer: 2.5 cm
Hydrocolloid dressings should extend at least 2.5 cm (1 inch) beyond wound edges to ensure adequate adhesion and seal.
Question 5: A patient receiving wound care refuses to allow the nurse to perform the dressing change. What is the most appropriate nursing response?
- Proceed with the dressing change to prevent wound infection
- Document the refusal, notify the provider, and ensure patient understands risks (Correct answer)
- Ask a family member to hold the patient still during the procedure
- Withhold pain medication until the patient agrees to the procedure
Correct answer: Document the refusal, notify the provider, and ensure patient understands risks
Competent patients have the right to refuse treatment; the nurse must document the refusal, educate about risks, and notify the provider.
Question 6: Which type of debridement involves using a wet-to-dry gauze dressing to remove necrotic tissue as the dressing dries and adheres to the wound?
- Enzymatic debridement
- Autolytic debridement
- Mechanical debridement (Correct answer)
- Sharp debridement
Correct answer: Mechanical debridement
Wet-to-dry dressings are a form of mechanical debridement where non-selective tissue removal occurs as the dressing adheres and is pulled away.
Question 7: A patient with a leg wound has periwound maceration. Which intervention should the LVN implement?
- Apply additional moisture to the wound bed to support healing
- Switch to a more absorbent dressing and apply a moisture barrier to periwound skin (Correct answer)
- Increase wound irrigation frequency to remove exudate
- Apply a wet-to-dry dressing to absorb excess moisture
Correct answer: Switch to a more absorbent dressing and apply a moisture barrier to periwound skin
Maceration indicates excess moisture; switching to a more absorbent dressing and protecting the periwound skin with a barrier prevents further tissue breakdown.
LVN Wound Care & Dressing Techniques 4
A patient with a sacral pressure injury receives negative pressure wound therapy (NPWT).
Which finding requires the LVN to stop the therapy and notify the provider immediately?