ATI LPN
Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 26 : Wound Care Questions
Question 1 of 5
Which one of the following assessment findings makes it impossible to stage a pressure injury?
Correct Answer: B
Rationale: Eschar obscures the wound bed, making it impossible to assess the depth and stage of a pressure injury.
Question 2 of 5
The phase of healing during which granulation tissue forms in a wound is the:
Correct Answer: B
Rationale: Granulation tissue forms during the reconstruction (proliferative) phase, filling the wound with new tissue.
Question 3 of 5
You observe pink drainage from a patient's wound. You would describe this as:
Correct Answer: E
Rationale: Serosanguineous drainage is pink, combining clear serous fluid and small amounts of blood.
Question 4 of 5
Your patient has a large abdominal wound with copious drainage and many layers of gauze 4x4s in the dressing. The patient develops a skin reaction to the tape due to frequent dressing changes. What might you recommend for this patient?
Correct Answer: C
Rationale: Montgomery straps or an abdominal binder reduce skin irritation by minimizing tape use while securing dressings.
Question 5 of 5
A patient returns from surgery with a left shoulder dressing. A 3-inch diameter spot of red drainage is visible on the anterior portion of the dressing. The health-care provider does not want the dressing disturbed for 24 hours. What will you do?
Correct Answer: C,D
Rationale: Outlining and documenting the drainage allows monitoring for expansion without disturbing the dressing, per provider orders.