NCLEX-PN Test #20 2

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?

Accepted Answer

Stage III — full-thickness skin loss with visible subcutaneous tissue

Answer

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?

Accepted Answer

Normal saline using a 35 mL syringe with an 18-gauge angiocath to deliver 8–15 PSI irrigation pressure

Answer

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?

Accepted Answer

Surgical/sharp debridement

Answer

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?

Accepted Answer

Hydrocolloid dressing (DuoDERM) changed every 3–5 days

Answer

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:

Accepted Answer

Applying negative pressure (suction) to remove exudate, reduce edema, and stimulate granulation tissue formation

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #20 2