NCLEX-PN Test #20 2 — Questions and Answers
Question 1: The PN assesses a client's sacral area and finds a 4 cm × 3 cm wound with full-thickness tissue loss down to subcutaneous fat. The wound base is yellow with slough but no bone or tendon is visible. How should this wound be staged?
- Stage I — non-blanchable erythema
- Stage II — partial-thickness skin loss
- Stage III — full-thickness skin loss with visible subcutaneous tissue (Correct answer)
- Stage IV — full-thickness tissue loss with exposed bone/tendon/muscle
Correct answer: Stage III — full-thickness skin loss with visible subcutaneous tissue
NPUAP staging: Stage I = non-blanchable erythema on intact skin; Stage II = partial thickness loss of dermis; Stage III = full-thickness loss to subcutaneous fat (bone/tendon not exposed); Stage IV = full-thickness loss with exposed bone, tendon, or muscle. The described wound (full-thickness to fat, no bone visible) = Stage III.
Question 2: A client requires wound irrigation. What is the appropriate solution and pressure for wound irrigation?
- Undiluted betadine solution applied with a syringe as fast as possible
- Normal saline using a 35 mL syringe with an 18-gauge angiocath to deliver 8–15 PSI irrigation pressure (Correct answer)
- Hydrogen peroxide diluted 1:1 with normal saline using gentle pressure
- Sterile water applied directly from the bottle in a stream
Correct answer: Normal saline using a 35 mL syringe with an 18-gauge angiocath to deliver 8–15 PSI irrigation pressure
Evidence-based wound irrigation uses normal saline (isotonic, non-cytotoxic) delivered at 8–15 PSI using a 35 mL syringe with an 18-gauge catheter. This pressure is sufficient to remove debris without damaging tissue. Betadine and hydrogen peroxide are cytotoxic to granulation tissue. Too little pressure (< 4 PSI) is inadequate; too much (> 15 PSI) damages tissue.
Question 3: A client has a stage IV pressure injury over the right ischium with visible bone. Which type of wound debridement is most appropriate for removing large amounts of necrotic tissue rapidly?
- Autolytic debridement (moisture-retentive dressings)
- Enzymatic debridement (collagenase)
- Surgical/sharp debridement (Correct answer)
- Mechanical debridement (wet-to-dry gauze)
Correct answer: Surgical/sharp debridement
Surgical or sharp debridement is the fastest and most effective method for removing large amounts of necrotic tissue. It is performed by a qualified provider and is indicated for infected wounds or when rapid debridement is needed. Autolytic debridement is slow but selective; enzymatic is chemical; mechanical debridement is non-selective and painful.
Question 4: The nurse is caring for a diabetic client with a foot ulcer that has pale pink granulation tissue and minimal drainage. Which type of dressing best supports continued moist wound healing?
- Dry gauze changed three times daily
- Wet-to-dry saline gauze
- Hydrocolloid dressing (DuoDERM) changed every 3–5 days (Correct answer)
- Dry iodine-soaked gauze
Correct answer: Hydrocolloid dressing (DuoDERM) changed every 3–5 days
Moist wound healing optimizes cell migration, growth factor activity, and reepithelialization. Hydrocolloid dressings maintain a moist environment, protect from contamination, provide cushioning, and require less frequent changes (every 3–5 days), which reduces wound disruption. Dry dressings and wet-to-dry gauze impede healing by drying the wound bed.
Question 5: A client with a diabetic foot ulcer is scheduled for vacuum-assisted closure (VAC) therapy. The nurse explains that the device works by:
- Delivering targeted antibiotic therapy directly to the wound bed
- Applying negative pressure (suction) to remove exudate, reduce edema, and stimulate granulation tissue formation (Correct answer)
- Providing photobiomodulation (light therapy) to accelerate wound closure
- Maintaining a consistently warm temperature at the wound bed
Correct answer: Applying negative pressure (suction) to remove exudate, reduce edema, and stimulate granulation tissue formation
Negative pressure wound therapy (NPWT/VAC) applies controlled subatmospheric pressure (typically −125 mmHg) to the wound bed via a foam dressing and sealed dressing system. This removes excess fluid and exudate, reduces edema, increases local blood flow, stimulates granulation tissue, and draws wound edges together.
Question 6: A client who smokes is recovering from a surgical wound. The nurse teaches that smoking impairs wound healing primarily by:
- Increasing appetite and causing obesity, which puts tension on the wound
- Causing vasoconstriction and reducing oxygen delivery to wound tissues, impairing collagen synthesis (Correct answer)
- Inhibiting platelet aggregation only, causing excessive wound bleeding
- Increasing gastric acid production, which prevents normal nutritional intake
Correct answer: Causing vasoconstriction and reducing oxygen delivery to wound tissues, impairing collagen synthesis
Nicotine causes vasoconstriction, reducing blood flow to wound tissues. Carbon monoxide in cigarette smoke binds hemoglobin (forming carboxyhemoglobin), further reducing oxygen delivery. Hypoxia impairs fibroblast activity and collagen synthesis — both essential for wound healing. Smoking is associated with wound dehiscence, infection, and delayed healing.
NCLEX-PN Test #20 2
The PN assesses a client's sacral area and finds a 4 cm × 3 cm wound with full-thickness tissue loss down to subcutaneous fat.
The wound base is yellow with slough but no bone or tendon is visible.
How should this wound be staged?