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

A Stage III pressure injury involves full-thickness skin loss with visible subcutaneous fat but without exposed bone, tendon, or muscle. Stage IV would involve exposed bone, tendon, or muscle.

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

Wet-to-dry dressings provide mechanical debridement: the dressing is moistened, placed in the wound, and as it dries it adheres to necrotic tissue. When removed, the dead tissue is pulled away. This technique is non-selective and may also remove healthy tissue.

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

Bright red blood indicates arterial bleeding, which is a hemorrhagic emergency. The nurse should apply direct pressure immediately to control bleeding and call for help. Removing the dressing would remove the tamponade effect and worsen bleeding.

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

Effective wound irrigation uses a 35 mL syringe with an 18-gauge angiocatheter to deliver saline at 8–15 psi — sufficient pressure to remove debris without traumatizing wound tissue. Irrigation should proceed from the cleanest to the dirtiest area.

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

Wound dehiscence requires immediate intervention. The nurse should cover the wound with a sterile saline-moistened dressing to keep exposed tissue moist and prevent infection, then notify the surgeon immediately. The patient should be placed in low Fowler's position with knees slightly flexed to reduce tension on the wound.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #13 1