NCLEX-PN Test #13 1

Question 1

A nurse assesses a pressure injury with full-thickness skin loss, visible subcutaneous fat, and no exposed bone or tendon. How should this wound be staged?

Accepted Answer

Stage III

Answer

Stage I

Answer

Stage II

Answer

Stage IV

Question 2

A nurse is performing a wet-to-dry dressing change on a wound with necrotic tissue. What is the primary purpose of this dressing technique?

Accepted Answer

Provide mechanical debridement

Answer

Promote autolytic debridement

Answer

Keep the wound moist to support granulation

Answer

Reduce wound odor

Question 3

While performing a dressing change, a nurse observes bright red blood suddenly saturating the wound dressing. What is the priority nursing action?

Accepted Answer

Apply direct pressure and call for immediate assistance

Answer

Remove the dressing and irrigate the wound

Answer

Document the finding and notify the physician at next rounds

Answer

Elevate the affected extremity and continue the dressing change

Question 4

A nurse is irrigating a deep wound with normal saline. Which action reflects proper wound irrigation technique?

Accepted Answer

Use a 35 mL syringe with an 18-gauge angiocatheter to deliver fluid at 8–15 psi

Answer

Use a dry cotton swab to remove debris before irrigation

Answer

Direct the irrigation stream from the dirtiest to cleanest area

Answer

Fill the wound basin and allow fluid to soak for 10 minutes

Question 5

A patient's surgical wound edges are separated with visible subcutaneous tissue. The nurse identifies this as wound dehiscence. What is the immediate nursing action?

Accepted Answer

Cover the wound with a sterile saline-moistened dressing and notify the surgeon immediately

Answer

Apply a dry sterile dressing and document

Answer

Irrigate the wound with povidone-iodine and reapply the original dressing

Answer

Ask the patient to apply pressure to the wound edges and call the charge nurse

Question 6

A nurse is caring for a patient with a venous stasis ulcer on the lower leg. Which intervention is most important to include in the plan of care?

Accepted Answer

Apply compression therapy as prescribed

Answer

Keep the leg in a dependent position to improve circulation

Answer

Use only dry dressings to prevent maceration

Answer

Restrict ambulation to prevent further skin breakdown