LVN Wound Care & Dressing Techniques 5 — Questions and Answers
Question 1: An LVN is performing a dressing change on a patient with a draining abdominal wound. The patient asks why the nurse is wearing a mask and goggles. The BEST response is:
- 'These are required for all wound care procedures regardless of drainage.'
- 'I wear these to protect myself from splashing wound drainage that could carry infection.' (Correct answer)
- 'Hospital policy requires this for all patient interactions.'
- 'I wear these because your wound smells and I want to reduce exposure.'
Correct answer: 'I wear these to protect myself from splashing wound drainage that could carry infection.'
Eye protection and masks are required when there is risk of splashing body fluids; explaining the rationale accurately respects patient understanding.
Question 2: Which finding in a pressure injury indicates that it has progressed to an unstageable wound?
- The wound measures more than 10 cm in diameter
- The wound bed is completely covered by eschar or slough obscuring its depth (Correct answer)
- The wound has tunneling greater than 2 cm
- The wound has been present for more than 30 days without healing
Correct answer: The wound bed is completely covered by eschar or slough obscuring its depth
Unstageable pressure injuries cannot be staged because the wound base is obscured by slough or eschar, making it impossible to assess true depth.
Question 3: A patient with a surgical wound develops a fever of 38.8°C (101.8°F) on postoperative day 3 with increased wound pain, redness, and purulent drainage. These findings are MOST consistent with:
- Normal inflammatory phase of wound healing
- Wound dehiscence
- Surgical site infection (Correct answer)
- Seroma formation
Correct answer: Surgical site infection
Fever, increased pain, erythema, and purulent drainage on POD 3 are classic signs of a surgical site infection requiring provider notification.
Question 4: When packing a deep wound with gauze, the LVN should:
- Pack the wound firmly and tightly to apply pressure and control bleeding
- Lightly pack the wound to gently fill dead space without causing pressure (Correct answer)
- Leave the wound unpacked and covered with a transparent film
- Pack only the wound edges, leaving the center open to air
Correct answer: Lightly pack the wound to gently fill dead space without causing pressure
Wound packing should lightly fill dead space to promote healing from the base up; tight packing restricts blood flow and impairs healing.
Question 5: A patient is discharged home with wound care instructions. Which statement by the patient indicates understanding of signs of wound infection to report?
- 'I should call if the wound looks pink around the edges for the first few days.'
- 'I should call if I notice increasing redness, warmth, swelling, or pus from the wound.' (Correct answer)
- 'I should call if I see clear fluid leaking from the wound in the first 24 hours.'
- 'I should call if the wound forms a scab within the first week.'
Correct answer: 'I should call if I notice increasing redness, warmth, swelling, or pus from the wound.'
Increasing redness, warmth, swelling, and purulent drainage are classic signs of infection that require prompt medical evaluation.
Question 6: Which dressing change frequency is most appropriate for a transparent film dressing applied over a clean, low-exudate wound?
- Every 8 hours
- Every 24 hours
- Every 3–7 days or when integrity is compromised (Correct answer)
- Every 12 hours
Correct answer: Every 3–7 days or when integrity is compromised
Transparent film dressings can remain in place for 3–7 days unless they become loose, soiled, or the wound condition changes.
Question 7: A patient with an arterial leg ulcer has a pale, dry wound base with minimal exudate and the leg is cool to touch. The priority nursing action is:
- Apply compression bandaging to improve circulation
- Assess peripheral pulses and report to the provider before initiating treatment (Correct answer)
- Irrigate the wound with warm saline and apply a moisture dressing
- Elevate the limb above heart level to reduce swelling
Correct answer: Assess peripheral pulses and report to the provider before initiating treatment
Arterial ulcers indicate compromised arterial blood flow; assessing peripheral pulses and reporting to the provider is essential before any treatment, as compression is contraindicated.
LVN Wound Care & Dressing Techniques 5
An LVN is performing a dressing change on a patient with a draining abdominal wound.
The patient asks why the nurse is wearing a mask and goggles.
The BEST response is: