Some days after an injury, the nurse sees beefy red, bumpy tissue filling the wound bed while the wound edges pull inward. Which phase of healing is underway?
Proliferation
✓
Hemostasis
Inflammation
Maturation and remodeling
Correct Answer
Proliferation
During proliferation, fibroblasts lay down new collagen, new capillaries form, granulation tissue fills the wound and the edges contract. Hemostasis is the opening phase, when vessels constrict and a clot stops the bleeding. Inflammation brings redness, swelling and white blood cells that clean the wound bed. Maturation and remodeling is the long final phase in which collagen reorganizes into scar tissue.
Category: Healing Process
Question 2
During a dressing change, the nurse finds that the granulation tissue is dark and friable and bleeds with gentle cleansing. What does this suggest?
Healthy, well-progressing granulation
Possible wound infection
✓
A fully matured scar
Normal early clot formation
Correct Answer
Possible wound infection
Healthy granulation tissue is pink to red, moist and bumpy and does not bleed easily, so dark, friable tissue that bleeds with light touch may signal infection and should be reported. Healthy, well-progressing granulation would be pink or red and sturdy. A fully matured scar is flat and pale and has no open granulating bed. Normal early clot formation happens at the time of injury, not as tissue that keeps bleeding during later dressing changes.
Category: Healing Process
Question 3
A pressure injury is left open to heal from the bottom up with granulation tissue. Why does it need closer monitoring than a sutured surgical incision?
Wounds healing this way cannot form new blood vessels
The edges of this wound are already brought together
Open healing carries a higher risk of infection and scarring
✓
Open wounds heal faster and need dressings removed sooner
Correct Answer
Open healing carries a higher risk of infection and scarring
Healing by secondary intention leaves the wound open for a long time while it fills with granulation tissue, so infection and scarring are more likely than with primary closure. The claim that wounds healing this way cannot form new blood vessels is wrong, since new capillaries are part of granulation tissue. Edges that are already brought together describe primary intention. The claim that open wounds heal faster and need dressings removed sooner is wrong, because primary intention is the fastest type of closure.
Category: Healing Process
Question 4
A patient is scheduled for hyperbaric oxygen therapy for a nonhealing wound. Which history should the nurse report before the first session?
A healed ankle fracture
Mild osteoarthritis of the knees
A family history of diabetes
Recent ear surgery
✓
Correct Answer
Recent ear surgery
Pressure changes in the chamber stress the middle ear, and middle ear trauma is the most common complication of hyperbaric oxygen therapy, so recent ear injury or surgery is a reason to hold treatment. A healed ankle fracture does not affect the response to chamber pressure. Mild osteoarthritis of the knees is not a contraindication. A family history of diabetes describes a relative's risk, not a problem that pressurized oxygen would worsen.
Category: Specialized Wound Care
Question 5
A patient with a leg wound is shivering in a cool room and is anxious about a dressing change. Why does the nurse warm the patient and address the anxiety?
Cold and fear constrict vessels and cut oxygen to the wound
✓
Warmth makes topical antibiotics work faster
Shivering pulls the wound edges apart
Cool air dries the dressing too quickly
Correct Answer
Cold and fear constrict vessels and cut oxygen to the wound
Healing tissue has high metabolic needs met by oxygen and glucose from new vessels, and cold, fear, pain, nicotine and low blood volume all cause vasoconstriction that reduces that supply. Making topical antibiotics work faster is not the reason for warming. Shivering does not pull the wound edges apart. Cool air drying the dressing too quickly is not how cold impairs healing; the harm comes from reduced blood flow.
Category: Healing Process
Question 6
A nurse is unsure which stage to assign to a patient's pressure injury. What should the nurse do?
Assign the deeper of the possible stages
Describe the wound exactly as assessed
✓
Assign the shallower of the possible stages
Leave the wound out of the record until it changes
Correct Answer
Describe the wound exactly as assessed
Staging carries clinical and legal weight, so when the nurse cannot tell which stage applies, the nurse documents a precise, objective description of the wound as assessed and seeks a wound specialist's input. Assigning the deeper of the possible stages records a stage that the assessment does not support. Assigning the shallower of the possible stages may understate a serious injury. Leaving the wound out of the record until it changes creates a documentation gap that can be read as negligence.
Category: Pressure Injury
Question 7
Which finding over the sacrum of a patient with dark skin may signal an early pressure injury?
Redness that fades completely when pressed
Skin identical in color and texture to nearby skin
Skin that feels warmer and firmer than the surrounding skin
✓
A dry, flaky patch that is soft to the touch
Correct Answer
Skin that feels warmer and firmer than the surrounding skin
Blanching can be hard to see in darker skin, so the nurse relies on changes in temperature, firmness, sensation and a color darker or lighter than the nearby skin. Redness that fades completely when pressed is blanchable and shows the tissue is still perfused. Skin identical in color and texture to nearby skin shows no sign of injury. A dry, flaky patch that is soft to the touch suggests dryness rather than pressure damage.
Category: Pressure Injury
Question 8
A wound care plan includes a skin substitute made from pig tissue. What should the nurse do before it is applied?
Apply it without discussion because it is a medical product
Ask only the provider whether the patient would object
Replace it with a dressing of the nurse's choosing
Tell the patient the product's source so preferences can be honored
✓
Correct Answer
Tell the patient the product's source so preferences can be honored
Some patients avoid pork-derived products for religious, cultural or personal reasons, so the nurse discloses animal-derived ingredients and helps arrange an alternative if the patient objects. Applying it without discussion because it is a medical product ignores the patient's right to an informed choice. Asking only the provider whether the patient would object leaves the patient out of the decision. Replacing it with a dressing of the nurse's choosing changes the prescribed plan without an order.
Category: Specialized Wound Care
Question 9
Over the sacrum of a patient who has been lying on the back, intact skin shows a persistent deep maroon area that does not blanch. What does the nurse do next?
Turn the patient off the area and reassess it often
✓
Massage the area firmly to restore blood flow
Wait until the skin opens before changing the plan
Record it as moisture damage and apply a barrier cream
Correct Answer
Turn the patient off the area and reassess it often
Persistent nonblanchable deep red, maroon or purple discoloration signals a deep tissue pressure injury, damage at the bone-muscle interface that may evolve to reveal deeper tissue loss or resolve without it, so the nurse keeps all pressure off the area and reassesses it frequently. Massaging the area firmly can further damage the injured deep tissue. Waiting until the skin opens lets the injury progress while it may still be reversible. Recording it as moisture damage misreads a pressure injury, because moisture damage affects the skin surface after exposure to incontinence or sweat.
Category: Pressure Injury
Question 10
A bedbound patient has dry, intact black eschar firmly attached to the heel with no redness, swelling or drainage. What is the plan for the eschar?
Soften it with a hydrogel so it lifts away
Leave it in place and protect the heel from pressure
✓
Remove it with wet-to-dry dressings
Score it with a scalpel at the bedside
Correct Answer
Leave it in place and protect the heel from pressure
Stable, dry, adherent heel eschar acts as a natural biological cover and is not softened or removed; the heel is offloaded and watched for signs of infection or instability. Softening it with a hydrogel so it lifts away would break down that protective barrier. Removing it with wet-to-dry dressings is nonselective and painful. Scoring it with a scalpel at the bedside opens the tissue to infection.
Category: Debridement
Question 11
A patient in a wheelchair asks for a ring-shaped cushion to relieve pressure on the sacrum. How should the nurse respond?
Provide it because it fully offloads the sacrum
Provide it but only while the patient sleeps
Explain that it concentrates pressure on the surrounding tissue
✓
Explain that it is meant only for patients with heel wounds
Correct Answer
Explain that it concentrates pressure on the surrounding tissue
Donut or ring cushions press on the tissue around the opening, reducing blood flow and raising the risk of injury, so frequent repositioning and appropriate support surfaces are used instead. Providing it because it fully offloads the sacrum is wrong for that reason. Providing it only while the patient sleeps still concentrates pressure. Explaining that it is meant only for patients with heel wounds is inaccurate, because these cushions are not recommended for any area.
Category: Pressure Injury
Question 12
A patient receiving oxygen by nasal cannula develops a wound behind the ears that matches the shape of the tubing. How is it classified?
Allergic contact dermatitis
Friction blister
Moisture-associated skin damage
Medical device-related pressure injury
✓
Correct Answer
Medical device-related pressure injury
Prolonged pressure from a diagnostic or therapeutic device produces an injury that takes the device's shape, and it is staged with the usual system. Allergic contact dermatitis is an itchy rash from a substance, not a wound shaped like the device. A friction blister forms from rubbing rather than sustained pressure. Moisture-associated skin damage comes from prolonged wetness.
Category: Pressure Injury
Question 13
A patient with diabetic neuropathy has a round ulcer on the sole of the foot with thick, callused edges. Which treatment is central to healing it?
Relieving pressure on the area with offloading
✓
Applying a heating pad to the foot
Keeping the wound open to air to dry
Walking barefoot to toughen the skin
Correct Answer
Relieving pressure on the area with offloading
Diabetic foot ulcers result from neuropathy, poor circulation and poor glycemic control, and offloading pressure, glucose control and debridement of callus and dead tissue are the core treatments. Applying a heating pad to the foot risks burns in a foot that cannot sense heat. Keeping the wound open to air to dry is outdated because moist healing is preferred. Walking barefoot to toughen the skin adds pressure and injury risk.
Category: Specialized Wound Care
Question 14
Which finding would lead the provider to postpone sharp debridement at the bedside?
Thick, adherent necrotic tissue
Current anticoagulant therapy
✓
A large amount of nonviable tissue
A chronic wound that has stopped healing
Correct Answer
Current anticoagulant therapy
Sharp debridement cuts away tissue and can cause bleeding, so anticoagulation, bleeding disorders, hemodynamic instability and stable intact eschar without infection are reasons for caution. Thick, adherent necrotic tissue is an indication for sharp debridement. A large amount of nonviable tissue is also an indication. A chronic wound that has stopped healing often needs debridement to restart the healing process.
Category: Debridement
Question 15
Why are wet-to-dry gauze dressings used less often than in the past?
They keep the wound bed too moist to heal
They require a prescription enzyme to work
They pull away healthy tissue along with dead tissue
✓
They can be changed only by a surgeon
Correct Answer
They pull away healthy tissue along with dead tissue
Wet-to-dry dressings debride mechanically and nonselectively, removing viable tissue with necrotic tissue, and they are painful, need frequent changes, can macerate surrounding skin and release airborne organisms. Keeping the wound bed too moist is not the problem, because the gauze dries out. Needing a prescription enzyme describes enzymatic debridement, not gauze. Being limited to surgeons is not true, because nurses perform these changes.
Category: Debridement
Question 16
For which wound is a hydrocolloid dressing a poor choice?
A shallow wound with light drainage
A clean partial-thickness wound
A wound that needs a long wear time
An infected wound
✓
Correct Answer
An infected wound
Hydrocolloids are occlusive, self-adhesive wafers suited to shallow wounds with little drainage, but sealing over an infected wound can let bacteria multiply, so they are contraindicated there. A shallow wound with light drainage is a typical use. A clean partial-thickness wound is also appropriate. A wound that needs a long wear time fits, because hydrocolloids can stay in place for several days.
Category: Wound Assessment and Dressings
Question 17
Which dressing suits a wound with heavy drainage?
Alginate
✓
Transparent film
Hydrogel
Hydrocolloid
Correct Answer
Alginate
Alginates are fibers derived from seaweed that absorb moderate to heavy drainage and form a gel that allows gentle removal. Transparent film has no absorptive capacity. Hydrogel donates moisture and suits dry wounds. Hydrocolloid suits shallow wounds with light drainage.
Category: Wound Assessment and Dressings
Question 18
A patient has a dry, punched-out ulcer on the toes that is very painful at night. Which treatment is avoided until perfusion studies are done?
Moist wound dressings
Compression wrapping
✓
Regular pain assessment
Gentle saline cleansing
Correct Answer
Compression wrapping
These features point to an arterial ulcer caused by poor perfusion, and compression can cut blood flow further, so it is contraindicated until studies such as the ankle-brachial index confirm adequate circulation. Moist wound dressings are the recommended topical approach. Regular pain assessment is needed because these ulcers can be very painful. Gentle saline cleansing is noncytotoxic and safe.
Category: Specialized Wound Care
Question 19
When cleansing a sutured incision, how does the nurse move the gauze?
From the outer skin toward the suture line, reusing one gauze
In a back-and-forth scrubbing motion across the incision
From the suture line outward, with a new gauze for each stroke
✓
In circles from the outer edge inward
Correct Answer
From the suture line outward, with a new gauze for each stroke
The suture line is the least contaminated area, so cleansing moves from clean to dirty, starting at the incision and moving outward with a fresh moistened gauze for each stroke. Moving from the outer skin toward the suture line while reusing one gauze carries microorganisms into the incision. Scrubbing back and forth across the incision recontaminates cleaned areas and can injure new tissue. Circling from the outer edge inward also moves from dirty to clean.
Category: Wound Assessment and Dressings
Question 20
The nurse notes thin, watery, pink drainage on a surgical dressing. How is this documented?
Serous
Sanguineous
Purulent
Serosanguineous
✓
Correct Answer
Serosanguineous
Serosanguineous drainage is thin, watery and pink because it is serum tinged with blood. Serous drainage is clear to amber and watery. Sanguineous drainage is bloody and red. Purulent drainage is thick, opaque and yellow or green and suggests infection.
Category: Wound Assessment and Dressings