✨ Introduction
Wound care is one of the most frequently tested topics on the NCLEX-RN and NCLEX-PN exams. It assesses your ability to apply nursing judgment, prioritize care, and understand the principles of wound assessment, infection control, and healing processes. Whether you are preparing for your upcoming NCLEX or brushing up on your clinical knowledge, this comprehensive practice set will help you master the topic with confidence.
In this guide, we’ve compiled 100 exam-focused NCLEX wound care practice questions with detailed rationales — based on real exam patterns, clinical guidelines, and test-taker feedback. Each question is designed to simulate the critical-thinking style of the NCLEX, helping you not only memorize facts but also understand why each answer is correct.
🧩 NCLEX Wound Care Practice Questions – Part 1 (1–25)
Q1. A nurse is assessing a surgical wound 48 hours post-operation. Which finding indicates a potential infection?
A. Slight swelling at the incision site
B. Serosanguinous drainage
C. Increased warmth and purulent discharge
D. Mild tenderness around the wound
✅ Correct Answer: C. Increased warmth and purulent discharge
🩻 Rationale: Warmth, purulent drainage, and swelling indicate infection. Mild redness and tenderness are normal within the first few days post-op.
Q2. A patient with a pressure injury on the heel should have which priority nursing intervention?
A. Apply a heat pack to promote circulation
B. Keep the heel elevated off the bed
C. Massage the area every 2 hours
D. Cover with a dry sterile dressing
✅ Correct Answer: B. Keep the heel elevated off the bed
🩻 Rationale: Elevating the heel prevents further pressure and promotes healing. Heat and massage can worsen tissue damage.
Q3. A wound with red granulation tissue should be cleaned using which method?
A. Alcohol swab
B. Normal saline irrigation
C. Hydrogen peroxide
D. Betadine solution
✅ Correct Answer: B. Normal saline irrigation
🩻 Rationale: Normal saline is non-toxic and preserves granulation tissue. Harsh antiseptics damage new tissue.
Q4. During wound dressing, the nurse should wear sterile gloves during which step?
A. Removing the old dressing
B. Cleaning the wound with saline
C. Opening the sterile dressing tray
D. Documenting the procedure
✅ Correct Answer: B. Cleaning the wound with saline
🩻 Rationale: Sterile gloves prevent contamination when directly handling or cleaning the wound bed.
Q5. Which wound type heals primarily by secondary intention?
A. Clean surgical incision
B. Sutured laceration
C. Large open wound with tissue loss
D. Closed wound with staples
✅ Correct Answer: C. Large open wound with tissue loss
🩻 Rationale: Secondary intention healing occurs when tissue loss prevents primary closure, requiring granulation and contraction.
Q6. When assessing a stage 2 pressure injury, the nurse expects to find:
A. Intact skin with redness
B. Partial-thickness skin loss involving the dermis
C. Full-thickness tissue loss with bone exposure
D. Eschar covering the wound bed
✅ Correct Answer: B. Partial-thickness skin loss involving the dermis
🩻 Rationale: Stage 2 pressure injuries show partial skin loss, while stage 3 or 4 involve deeper tissue damage.
Q7. Which nutrient is most essential for collagen synthesis and wound healing?
A. Vitamin A
B. Vitamin C
C. Iron
D. Vitamin D
✅ Correct Answer: B. Vitamin C
🩻 Rationale: Vitamin C promotes collagen production and capillary formation, speeding up wound healing.
Q8. A diabetic client has a non-healing foot ulcer. The nurse’s priority is to:
A. Increase the patient’s fluid intake
B. Keep the wound dry
C. Monitor blood glucose levels
D. Apply a heating pad
✅ Correct Answer: C. Monitor blood glucose levels
🩻 Rationale: Poor glucose control delays healing and increases infection risk.
Q9. Which type of dressing maintains a moist wound environment?
A. Gauze
B. Transparent film
C. Hydrocolloid
D. Dry sterile pad
✅ Correct Answer: C. Hydrocolloid
🩻 Rationale: Hydrocolloid dressings retain moisture and promote autolytic debridement.
Q10. The nurse identifies that a wound dehisced. What should the nurse do first?
A. Apply a dry dressing
B. Notify the physician
C. Cover with sterile saline-soaked gauze
D. Document the finding only
✅ Correct Answer: C. Cover with sterile saline-soaked gauze
🩻 Rationale: Keeping the wound moist and sterile prevents infection until further medical management.
Q11. A nurse notes that a wound has yellow slough covering the wound bed. What is the best initial nursing action?
A. Apply dry gauze to the area
B. Perform mechanical debridement
C. Leave it open to air
D. Apply heat therapy
✅ Correct Answer: B. Perform mechanical debridement
🩻 Rationale: Yellow slough prevents healing and must be removed. Mechanical or enzymatic debridement helps clear necrotic tissue safely.
Q12. Which factor can delay wound healing the most?
A. Protein-rich diet
B. Adequate hydration
C. Poor perfusion and oxygenation
D. Regular wound cleaning
✅ Correct Answer: C. Poor perfusion and oxygenation
🩻 Rationale: Oxygen is essential for cellular repair. Inadequate circulation delays collagen formation and increases infection risk.
Q13. When performing wound irrigation, the nurse should:
A. Use gentle pressure and clean from least to most contaminated area
B. Use vigorous scrubbing to remove debris
C. Irrigate with hot sterile water
D. Start cleaning from outer edges to center
✅ Correct Answer: A. Use gentle pressure and clean from least to most contaminated area
🩻 Rationale: This method prevents pushing contaminants into the wound and maintains tissue integrity.
Q14. Which assessment finding is typical of a stage 3 pressure ulcer?
A. Redness over intact skin
B. Full-thickness tissue loss with visible fat
C. Exposed bone or tendon
D. Partial-thickness skin loss
✅ Correct Answer: B. Full-thickness tissue loss with visible fat
🩻 Rationale: Stage 3 involves full-thickness loss, possibly showing fat but not bone or muscle.
Q15. Which statement best explains the purpose of a wound culture?
A. To determine wound depth
B. To identify microorganisms causing infection
C. To evaluate wound drainage
D. To assess wound size
✅ Correct Answer: B. To identify microorganisms causing infection
🩻 Rationale: Wound culture guides antibiotic therapy by identifying specific pathogens.
Q16. Which wound dressing is most suitable for a wound with heavy exudate?
A. Transparent film
B. Hydrocolloid
C. Foam dressing
D. Dry gauze
✅ Correct Answer: C. Foam dressing
🩻 Rationale: Foam dressings absorb large amounts of drainage and maintain moisture balance.
Q17. A nurse observes evisceration of an abdominal wound. What should the nurse do first?
A. Push organs back into the cavity
B. Cover with a moist sterile dressing
C. Apply pressure to the wound
D. Document and wait for the surgeon
✅ Correct Answer: B. Cover with a moist sterile dressing
🩻 Rationale: Evisceration is a surgical emergency. The wound must be kept moist and sterile while notifying the surgeon immediately.
Q18. Which wound color indicates healthy healing tissue?
A. Black
B. Yellow
C. Red
D. Gray
✅ Correct Answer: C. Red
🩻 Rationale: Red tissue signifies healthy granulation and good perfusion.
Q19. The nurse is documenting wound characteristics. Which element must always be included?
A. Patient’s weight
B. Drainage type and amount
C. Family history
D. Medication list
✅ Correct Answer: B. Drainage type and amount
🩻 Rationale: Accurate documentation of drainage helps assess healing progress and infection risk.
Q20. A client with a stage 4 pressure ulcer complains of foul odor and fever. The nurse should suspect:
A. Inadequate nutrition
B. Wound contamination
C. Systemic infection or sepsis
D. Allergic reaction to dressing
✅ Correct Answer: C. Systemic infection or sepsis
🩻 Rationale: Odor, fever, and deep ulcers indicate possible systemic infection that requires urgent medical attention.
Q21. When applying a sterile dressing, the nurse should:
A. Touch the inside of the dressing with bare hands
B. Handle only the outer edges
C. Reuse the same dressing if clean
D. Apply without handwashing
✅ Correct Answer: B. Handle only the outer edges
🩻 Rationale: Handling edges maintains sterility of the wound contact surface.
Q22. Which of the following patients is at greatest risk for pressure injury?
A. A young patient with a sprained ankle
B. A patient with limited mobility and poor nutrition
C. A patient with hypertension
D. A patient with mild fever
✅ Correct Answer: B. A patient with limited mobility and poor nutrition
🩻 Rationale: Poor nutrition and immobility reduce skin resilience and increase pressure ulcer risk.
Q23. Which action should the nurse avoid during wound care?
A. Using sterile saline
B. Changing dressings regularly
C. Using alcohol to clean wound edges
D. Hand hygiene before procedure
✅ Correct Answer: C. Using alcohol to clean wound edges
🩻 Rationale: Alcohol is too harsh for open wounds and delays healing by damaging tissue.
Q24. A nurse is teaching wound prevention to a bedridden client. Which instruction is most effective?
A. “Turn every 2 hours and keep skin dry.”
B. “Use massage on reddened areas.”
C. “Increase salt intake.”
D. “Limit fluid intake.”
✅ Correct Answer: A. “Turn every 2 hours and keep skin dry.”
🩻 Rationale: Repositioning and dry skin maintenance prevent pressure injuries effectively.
Q25. Which clinical sign best indicates wound healing?
A. Decreased granulation tissue
B. Increased serous drainage
C. Reduced redness and closure of wound edges
D. Formation of thick scab
✅ Correct Answer: C. Reduced redness and closure of wound edges
🩻 Rationale: Healing is shown by epithelial growth and gradual closure of the wound edges with less drainage.
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🧩 NCLEX Wound Care Practice Questions – Part 2 (26–50)
Q26. A nurse is teaching a client about wound infection prevention at home. Which statement indicates a need for further teaching?
A. “I’ll wash my hands before touching the wound.”
B. “I will clean the wound daily with hydrogen peroxide.”
C. “I’ll keep the dressing clean and dry.”
D. “I will report any swelling or pus to my doctor.”
✅ Correct Answer: B. “I will clean the wound daily with hydrogen peroxide.”
🩻 Rationale: Hydrogen peroxide damages healthy tissue. Normal saline or mild soap and water are recommended.
Q27. Which patient requires the most immediate wound assessment?
A. A client with serosanguinous drainage
B. A client with a sudden increase in drainage and wound separation
C. A client with a dry dressing
D. A client with mild tenderness at the incision site
✅ Correct Answer: B. A client with a sudden increase in drainage and wound separation
🩻 Rationale: Sudden drainage and separation indicate possible dehiscence — a surgical emergency.
Q28. Which wound is considered a full-thickness wound?
A. Skin tear involving only epidermis
B. Blister over heel
C. Surgical incision extending into subcutaneous tissue
D. Abrasion
✅ Correct Answer: C. Surgical incision extending into subcutaneous tissue
🩻 Rationale: Full-thickness wounds involve dermis and subcutaneous tissue layers.
Q29. Which type of wound drainage is clear and watery?
A. Purulent
B. Serous
C. Sanguineous
D. Serosanguinous
✅ Correct Answer: B. Serous
🩻 Rationale: Serous drainage is clear and indicates normal healing. Purulent drainage is cloudy or yellow and signals infection.
Q30. The nurse should use sterile technique when:
A. Changing a dry dressing
B. Emptying a wound drainage bag
C. Performing wound irrigation
D. Removing tape from the skin
✅ Correct Answer: C. Performing wound irrigation
🩻 Rationale: Irrigation exposes the wound bed, so sterility prevents contamination.
Q31. A patient with a large open wound is placed on a high-protein diet. What is the primary reason?
A. Protein prevents dehydration
B. Protein increases platelet production
C. Protein promotes collagen synthesis and tissue repair
D. Protein decreases inflammation
✅ Correct Answer: C. Protein promotes collagen synthesis and tissue repair
🩻 Rationale: Protein is crucial for fibroblast function and new tissue formation.
Q32. Which intervention helps reduce shear injuries in bedridden patients?
A. Elevating the head of bed to 90 degrees
B. Keeping the bed flat and using draw sheets
C. Rubbing the back with lotion
D. Applying ice packs to pressure areas
✅ Correct Answer: B. Keeping the bed flat and using draw sheets
🩻 Rationale: Shear occurs when skin slides against sheets. Using draw sheets minimizes friction.
Q33. A nurse notes that a postoperative wound has dehisced slightly. Which nursing action is most appropriate?
A. Apply sterile saline dressing and notify surgeon
B. Tape the wound edges together tightly
C. Apply dry gauze and continue normal care
D. Cover wound with heat compress
✅ Correct Answer: A. Apply sterile saline dressing and notify surgeon
🩻 Rationale: Keeping wound moist and sterile prevents further separation while awaiting medical review.
Q34. Which wound dressing is best for autolytic debridement?
A. Hydrocolloid
B. Dry gauze
C. Transparent film
D. Wet-to-dry dressing
✅ Correct Answer: A. Hydrocolloid
🩻 Rationale: Hydrocolloid dressings retain moisture, allowing natural enzymes to debride necrotic tissue.
Q35. Which action demonstrates correct use of negative pressure wound therapy (NPWT)?
A. Leaving the foam dressing dry
B. Applying suction to promote drainage
C. Turning off suction for long periods
D. Using dry gauze under suction tubing
✅ Correct Answer: B. Applying suction to promote drainage
🩻 Rationale: NPWT creates a controlled vacuum that removes exudate, reduces edema, and stimulates tissue growth.
Q36. Which finding requires immediate intervention during wound care?
A. Slight bleeding at wound edge
B. Foul-smelling discharge
C. Minimal serous drainage
D. Pink granulation tissue
✅ Correct Answer: B. Foul-smelling discharge
🩻 Rationale: Odor and discoloration are signs of bacterial infection requiring medical evaluation.
Q37. Which wound should be left open to air?
A. Clean surgical wound
B. Stage 3 pressure injury
C. Small abrasions with no drainage
D. Diabetic ulcer
✅ Correct Answer: C. Small abrasions with no drainage
🩻 Rationale: Minor wounds with intact healing edges can be left open; others require protection and moisture balance.
Q38. Which nursing action prevents contamination when changing a wound dressing?
A. Cleaning from center to periphery
B. Cleaning from periphery to center
C. Reusing gloves between tasks
D. Using non-sterile gauze for deep wounds
✅ Correct Answer: A. Cleaning from center to periphery
🩻 Rationale: Cleaning from least to most contaminated area prevents spreading microorganisms into the wound.
Q39. Which stage of wound healing involves collagen deposition?
A. Inflammatory phase
B. Proliferative phase
C. Maturation phase
D. Hemostasis phase
✅ Correct Answer: B. Proliferative phase
🩻 Rationale: Collagen synthesis and granulation tissue formation occur during proliferation.
Q40. Which of the following factors increases risk for delayed wound healing?
A. Young age
B. Obesity
C. Adequate hydration
D. Controlled diabetes
✅ Correct Answer: B. Obesity
🩻 Rationale: Fatty tissue has poor blood supply, leading to slower healing and higher infection risk.
Q41. A patient with an abdominal incision develops serosanguinous drainage after coughing. What is the best nursing action?
A. Reinforce dressing and monitor
B. Remove the dressing immediately
C. Ignore the drainage
D. Apply heat pack
✅ Correct Answer: A. Reinforce dressing and monitor
🩻 Rationale: Mild serosanguinous drainage is common after coughing, but increased drainage should be reported.
Q42. Which laboratory test best reflects wound healing progress?
A. Hemoglobin level
B. Serum albumin
C. Serum potassium
D. Blood glucose
✅ Correct Answer: B. Serum albumin
🩻 Rationale: Low albumin indicates poor nutrition and delayed healing potential.
Q43. Which of the following is a priority in preventing surgical wound infection?
A. Maintaining normothermia
B. Applying tight dressing
C. Restricting fluids
D. Increasing patient mobility immediately
✅ Correct Answer: A. Maintaining normothermia
🩻 Rationale: Hypothermia impairs immune response and increases infection risk.
Q44. What type of drainage indicates infection?
A. Serous
B. Sanguineous
C. Serosanguinous
D. Purulent
✅ Correct Answer: D. Purulent
🩻 Rationale: Purulent drainage is thick, yellow/green, and foul-smelling — a hallmark of infection.
Q45. When removing a dressing that adheres to a wound, the nurse should:
A. Pull it off quickly
B. Soak with sterile saline before removal
C. Use forceps to tear off edges
D. Leave the old dressing on
✅ Correct Answer: B. Soak with sterile saline before removal
🩻 Rationale: Moistening reduces trauma to the wound and minimizes pain.
Q46. What is the main goal of using a sterile wound dressing?
A. To reduce itching
B. To promote sterility and absorb drainage
C. To keep the area dry
D. To hide the wound from view
✅ Correct Answer: B. To promote sterility and absorb drainage
🩻 Rationale: Sterile dressings prevent infection and support optimal healing conditions.
Q47. Which of the following is an example of primary intention healing?
A. Burn injury
B. Surgical incision with sutures
C. Pressure ulcer
D. Deep laceration with tissue loss
✅ Correct Answer: B. Surgical incision with sutures
🩻 Rationale: Primary intention occurs when wound edges are approximated by sutures or staples.
Q48. The nurse should reposition a bed-bound patient how often to prevent pressure ulcers?
A. Every 6 hours
B. Every 4 hours
C. Every 2 hours
D. Once per shift
✅ Correct Answer: C. Every 2 hours
🩻 Rationale: Frequent repositioning relieves pressure and maintains circulation to skin areas.
Q49. Which stage pressure ulcer involves exposed bone or tendon?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
✅ Correct Answer: C. Stage 4
🩻 Rationale: Stage 4 pressure injuries show full-thickness loss with exposed bone, tendon, or muscle.
Q50. The presence of eschar covering a wound bed means the wound is:
A. Healing normally
B. Unstageable until the eschar is removed
C. A stage 2 pressure injury
D. Ready for closure
✅ Correct Answer: B. Unstageable until the eschar is removed
🩻 Rationale: Eschar conceals wound depth; debridement is necessary before accurate staging.
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🧩 NCLEX Wound Care Practice Questions – Part 3 (51–75)
Q51. Which principle should the nurse follow when cleaning a surgical wound?
A. Clean from the outer edge toward the center
B. Clean from the center outward using new swabs each time
C. Use the same swab for the entire wound
D. Clean vigorously to remove all debris
✅ Correct Answer: B. Clean from the center outward using new swabs each time
🩻 Rationale: Cleaning from least to most contaminated area prevents infection spread and maintains asepsis.
Q52. A patient reports sharp pain and bleeding during dressing change. The nurse should:
A. Continue dressing change quickly
B. Stop the procedure and assess the wound
C. Apply additional gauze tightly
D. Leave the wound open to air
✅ Correct Answer: B. Stop the procedure and assess the wound
🩻 Rationale: Bleeding during dressing removal may indicate tissue trauma or reopened wound edges.
Q53. Which patient requires priority wound care assessment?
A. A patient with a dry incision
B. A patient with a wound that suddenly smells foul
C. A patient with mild redness around sutures
D. A patient reporting mild itching at the wound site
✅ Correct Answer: B. A patient with a wound that suddenly smells foul
🩻 Rationale: Odor suggests infection — immediate evaluation is necessary.
Q54. A nurse observes black necrotic tissue on a diabetic ulcer. What is the most appropriate next step?
A. Apply a dry dressing
B. Begin debridement as prescribed
C. Apply cold compresses
D. Cover with transparent film
✅ Correct Answer: B. Begin debridement as prescribed
🩻 Rationale: Necrotic tissue must be removed for proper healing and infection control.
Q55. Which wound drainage system maintains continuous suction?
A. Penrose drain
B. Jackson-Pratt (JP) drain
C. Hemovac drain
D. Both B and C
✅ Correct Answer: D. Both B and C
🩻 Rationale: JP and Hemovac drains are closed systems providing gentle, continuous suction to remove fluid buildup.
Q56. When assessing a wound with sutures, the nurse should report:
A. Mild redness around sutures
B. Slight tenderness
C. Separation of wound edges
D. Dry incision site
✅ Correct Answer: C. Separation of wound edges
🩻 Rationale: Dehiscence is a serious complication that must be reported immediately.
Q57. A nurse is caring for a patient with a vacuum-assisted closure (VAC) device. Which observation requires intervention?
A. Dressing collapsed inward
B. Device alarm sounding
C. Minimal drainage in tubing
D. Patient reports mild warmth at site
✅ Correct Answer: B. Device alarm sounding
🩻 Rationale: Alarm indicates suction interruption or system leak, requiring prompt troubleshooting.
Q58. Which wound description indicates infection?
A. Pale pink tissue
B. Warm, tender wound with yellow drainage
C. Small amount of serous fluid
D. Minimal redness around sutures
✅ Correct Answer: B. Warm, tender wound with yellow drainage
🩻 Rationale: These are classic signs of localized infection requiring evaluation and possible antibiotics.
Q59. Which nursing action prevents wound maceration?
A. Applying occlusive dressing on all wounds
B. Keeping peri-wound skin dry
C. Leaving exudate in place to retain moisture
D. Increasing saline irrigation frequency
✅ Correct Answer: B. Keeping peri-wound skin dry
🩻 Rationale: Moisture around wound edges softens skin, increasing breakdown risk — peri-wound dryness is crucial.
Q60. Which factor most slows postoperative wound healing?
A. Protein-rich diet
B. Smoking
C. Ambulation
D. Controlled glucose
✅ Correct Answer: B. Smoking
🩻 Rationale: Smoking reduces oxygen supply to tissues, delaying healing and increasing infection risk.
Q61. A patient’s wound is packed with moist gauze. The purpose of this technique is to:
A. Keep the wound completely dry
B. Promote autolytic debridement and healing
C. Increase tissue tension
D. Prevent granulation tissue formation
✅ Correct Answer: B. Promote autolytic debridement and healing
🩻 Rationale: Moist-to-dry packing helps remove debris and supports granulation.
Q62. The best time to administer analgesics for wound care is:
A. After the procedure
B. During the procedure
C. 30 minutes before the procedure
D. Only if the patient complains of pain afterward
✅ Correct Answer: C. 30 minutes before the procedure
🩻 Rationale: Administering before dressing changes allows peak pain relief during the intervention.
Q63. When teaching wound care to a patient’s family, the nurse should emphasize:
A. Using tap water for deep wound irrigation
B. Maintaining hand hygiene before and after wound care
C. Changing the dressing only if wet
D. Avoiding gloves to improve dexterity
✅ Correct Answer: B. Maintaining hand hygiene before and after wound care
🩻 Rationale: Proper hand hygiene is the single most effective way to prevent infection.
Q64. Which phase of wound healing involves wound contraction and collagen remodeling?
A. Inflammatory phase
B. Proliferative phase
C. Maturation phase
D. Hemostasis phase
✅ Correct Answer: C. Maturation phase
🩻 Rationale: The maturation phase strengthens tissue through collagen reorganization.
Q65. Which sign indicates proper wound healing after 3 days of surgery?
A. Redness and mild swelling around incision
B. Excessive pain and odor
C. Purulent drainage
D. Dehisced wound edges
✅ Correct Answer: A. Redness and mild swelling around incision
🩻 Rationale: Mild inflammation is part of the normal healing process within the first few days post-surgery.
Q66. A wound vac device promotes healing primarily by:
A. Increasing oxygen concentration
B. Removing exudate and stimulating blood flow
C. Drying out the wound
D. Maintaining a low temperature
✅ Correct Answer: B. Removing exudate and stimulating blood flow
🩻 Rationale: Negative pressure therapy removes fluids and promotes circulation for faster healing.
Q67. Which client would benefit most from pressure-relieving devices?
A. Ambulatory patient with arm laceration
B. Post-stroke patient with limited mobility
C. Young athlete with sprained ankle
D. Child with superficial abrasion
✅ Correct Answer: B. Post-stroke patient with limited mobility
🩻 Rationale: Immobile clients are at higher risk for pressure injuries and need preventive support surfaces.
Q68. Which observation suggests a wound is healing by secondary intention?
A. Closed edges with no drainage
B. Wound gradually filling with granulation tissue
C. Incision sealed with staples
D. Minimal scarring
✅ Correct Answer: B. Wound gradually filling with granulation tissue
🩻 Rationale: Secondary intention involves healing from the base upward, filling with granulation tissue.
Q69. Which solution is safest for wound irrigation?
A. Betadine
B. Normal saline
C. Hydrogen peroxide
D. Alcohol
✅ Correct Answer: B. Normal saline
🩻 Rationale: Normal saline is isotonic, gentle, and preserves new tissue growth.
Q70. When evaluating wound healing, the nurse notes increased drainage and odor. The next action should be:
A. Apply a new dressing and recheck later
B. Notify the healthcare provider
C. Add topical ointment
D. Leave dressing off for air drying
✅ Correct Answer: B. Notify the healthcare provider
🩻 Rationale: Increased drainage and odor indicate infection requiring medical evaluation.
Q71. A patient with a surgical wound asks why the doctor ordered protein supplements. The nurse explains:
A. Protein increases body temperature
B. Protein helps build new tissue and collagen
C. Protein reduces fluid retention
D. Protein decreases immune response
✅ Correct Answer: B. Protein helps build new tissue and collagen
🩻 Rationale: Protein is vital for tissue repair, immune function, and collagen production.
Q72. The nurse recognizes wound evisceration when:
A. Wound edges are slightly red
B. Internal organs protrude through incision
C. Drainage becomes serous
D. Staples appear loose
✅ Correct Answer: B. Internal organs protrude through incision
🩻 Rationale: Evisceration is a medical emergency requiring immediate sterile coverage and surgical intervention.
Q73. The nurse applies a transparent film dressing to a wound. What is the primary benefit of this dressing?
A. It keeps the wound completely dry
B. It allows oxygen exchange while keeping bacteria out
C. It absorbs large amounts of drainage
D. It requires daily changes
✅ Correct Answer: B. It allows oxygen exchange while keeping bacteria out
🩻 Rationale: Transparent films maintain a moist environment and act as bacterial barriers.
Q74. Which of the following actions can impair wound healing?
A. Maintaining moisture
B. Using tight bandages
C. Ensuring nutrition
D. Regular repositioning
✅ Correct Answer: B. Using tight bandages
🩻 Rationale: Tight dressings restrict blood flow and slow healing.
Q75. The nurse identifies a wound with 80% red tissue and 20% yellow slough. The most appropriate dressing is:
A. Dry gauze
B. Hydrocolloid or hydrogel
C. Transparent film
D. Absorbent foam
✅ Correct Answer: B. Hydrocolloid or hydrogel
🩻 Rationale: Moisture-retaining dressings like hydrocolloids support granulation while gently debriding slough.
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🩹 NCLEX Wound Care Practice Questions – Part 4 (Q76–100)
Q76. Which finding suggests a wound infection?
A. Serous drainage
B. Mild tenderness
C. Purulent drainage with odor
D. Dry dressing
✅ Correct Answer: C. Purulent drainage with odor
🩻 Rationale: Thick, odorous, colored discharge is a clear indication of infection and requires prompt medical attention.
Q77. A nurse observes a patient’s wound edges separating after coughing. What complication is this?
A. Dehiscence
B. Evisceration
C. Fistula
D. Hemorrhage
✅ Correct Answer: A. Dehiscence
🩻 Rationale: Dehiscence is partial or total separation of wound layers, often due to strain on the incision.
Q78. The nurse suspects wound evisceration. What should be done immediately?
A. Cover the wound with a sterile saline dressing
B. Apply pressure to stop bleeding
C. Remove the organs gently
D. Give pain medication only
✅ Correct Answer: A. Cover the wound with a sterile saline dressing
🩻 Rationale: Evisceration requires moist, sterile coverage and urgent surgical notification.
Q79. Which type of dressing is ideal for a dry necrotic wound?
A. Foam dressing
B. Hydrogel
C. Transparent film
D. Dry gauze
✅ Correct Answer: B. Hydrogel
🩻 Rationale: Hydrogel keeps the wound moist, rehydrates dead tissue, and promotes autolytic debridement.
Q80. A client has a stage 1 pressure ulcer. What should the nurse do first?
A. Apply a hydrocolloid dressing
B. Massage the reddened area
C. Reposition the client frequently
D. Apply antibiotic ointment
✅ Correct Answer: C. Reposition the client frequently
🩻 Rationale: Frequent repositioning prevents pressure buildup and allows skin recovery.
Q81. Which laboratory result is most critical to assess in a patient with delayed wound healing?
A. Hemoglobin
B. Serum albumin
C. Sodium
D. Potassium
✅ Correct Answer: B. Serum albumin
🩻 Rationale: Low albumin levels indicate poor nutrition and protein deficiency, delaying healing.
Q82. Which dressing allows visualization of the wound while protecting it from contaminants?
A. Foam dressing
B. Transparent film
C. Hydrocolloid
D. Gauze wrap
✅ Correct Answer: B. Transparent film
🩻 Rationale: Transparent film dressings provide a barrier while allowing continuous wound observation.
Q83. The nurse notes a wound with black eschar. What is the first step?
A. Leave the eschar in place
B. Debride necrotic tissue as ordered
C. Apply alcohol pads
D. Cover with dry gauze only
✅ Correct Answer: B. Debride necrotic tissue as ordered
🩻 Rationale: Black eschar must be removed to allow granulation and proper healing.
Q84. A patient’s wound is healing by secondary intention. This means:
A. Wound edges are closed by sutures
B. Healing occurs from the base up
C. The wound is intentionally left open
D. The wound heals without scarring
✅ Correct Answer: B. Healing occurs from the base up
🩻 Rationale: Secondary intention involves open wounds healing gradually with granulation tissue formation.
Q85. Which type of wound drainage is considered normal in the early postoperative period?
A. Purulent
B. Serosanguineous
C. Greenish
D. Thick yellow
✅ Correct Answer: B. Serosanguineous
🩻 Rationale: A mixture of clear and light pink fluid is normal for early healing.
Q86. What is the main purpose of using Montgomery straps?
A. To promote healing
B. To reduce pain
C. To secure dressings without repeated tape removal
D. To control infection
✅ Correct Answer: C. To secure dressings without repeated tape removal
🩻 Rationale: Montgomery straps minimize skin irritation from frequent tape changes.
Q87. A wound vacuum-assisted closure (VAC) promotes healing by:
A. Applying continuous suction to remove fluid
B. Keeping the wound open
C. Delivering antibiotics
D. Drying out necrotic tissue
✅ Correct Answer: A. Applying continuous suction to remove fluid
🩻 Rationale: Negative pressure removes exudate and stimulates granulation tissue formation.
Q88. Which of the following clients has the highest risk for poor wound healing?
A. Young adult with sprain
B. Diabetic patient with foot ulcer
C. Pregnant woman
D. Child with abrasion
✅ Correct Answer: B. Diabetic patient with foot ulcer
🩻 Rationale: Diabetes impairs circulation and immune response, delaying wound repair.
Q89. Which vitamin deficiency can delay wound healing the most?
A. Vitamin A
B. Vitamin C
C. Vitamin D
D. Vitamin K
✅ Correct Answer: B. Vitamin C
🩻 Rationale: Vitamin C is essential for collagen synthesis and tissue repair.
Q90. Which of the following wounds should heal by primary intention?
A. Surgical incision with sutures
B. Burn injury
C. Pressure ulcer
D. Large open trauma
✅ Correct Answer: A. Surgical incision with sutures
🩻 Rationale: Surgical wounds closed with sutures heal by primary intention — edges come together quickly.
Q91. A wound shows signs of maceration. The nurse should:
A. Add more moisture
B. Reduce dressing frequency
C. Apply absorbent dressing
D. Use occlusive film
✅ Correct Answer: C. Apply absorbent dressing
🩻 Rationale: Maceration occurs from excess moisture, requiring absorbent material to restore balance.
Q92. Which patient position helps prevent sacral pressure ulcers?
A. Supine
B. 30-degree lateral tilt
C. High Fowler’s
D. Prone
✅ Correct Answer: B. 30-degree lateral tilt
🩻 Rationale: This reduces direct pressure on sacral areas while maintaining comfort.
Q93. The Braden Scale is used to assess:
A. Pain tolerance
B. Risk for pressure ulcers
C. Nutritional intake
D. Infection severity
✅ Correct Answer: B. Risk for pressure ulcers
🩻 Rationale: The Braden Scale evaluates sensory perception, moisture, activity, and nutrition to estimate ulcer risk.
Q94. Which wound color represents necrotic tissue?
A. Red
B. Yellow
C. Black
D. Pink
✅ Correct Answer: C. Black
🩻 Rationale: Black coloration indicates dead, necrotic tissue that must be debrided.
Q95. What is the preferred irrigation solution for most wounds?
A. Povidone-iodine
B. Hydrogen peroxide
C. Normal saline
D. Alcohol solution
✅ Correct Answer: C. Normal saline
🩻 Rationale: Isotonic saline safely cleanses wounds without damaging healthy cells.
Q96. The nurse is applying a dressing using sterile technique. Which step maintains sterility?
A. Touching sterile field with clean gloves
B. Handling dressing only by edges
C. Reusing old dressing tape
D. Opening all packages simultaneously
✅ Correct Answer: B. Handling dressing only by edges
🩻 Rationale: Edges are safe zones; touching the center contaminates the sterile area.
Q97. Which of the following indicates wound healing complication?
A. Decreased drainage
B. Firm pink tissue
C. Separation of wound edges
D. Mild soreness
✅ Correct Answer: C. Separation of wound edges
🩻 Rationale: Edge separation (dehiscence) suggests delayed or compromised healing.
Q98. A nurse is removing sutures. Which finding warrants stopping the procedure and notifying the provider?
A. Slight redness
B. Mild bleeding
C. Wound edge separation
D. Scab formation
✅ Correct Answer: C. Wound edge separation
🩻 Rationale: Separation means wound is not fully healed — sutures should not be removed yet.
Q99. Which action best prevents infection during wound care?
A. Wearing gloves only
B. Performing proper hand hygiene
C. Using clean rather than sterile supplies
D. Cleaning wound once daily only
✅ Correct Answer: B. Performing proper hand hygiene
🩻 Rationale: Hand hygiene remains the single most effective method to prevent infection.
Q100. A nurse documents that a wound is “healing by granulation.” This indicates:
A. Normal healing process
B. Infection
C. Dehiscence
D. Complication
✅ Correct Answer: A. Normal healing process
🩻 Rationale: Granulation tissue formation indicates the wound is filling and healing as expected.
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🩺 Conclusion: Master NCLEX Wound Care Topics
Wound care is a core area in the NCLEX-RN and NCLEX-PN exams, testing clinical judgment, infection control, and prioritization skills.
These 100 NCLEX Wound Care Practice Questions with rationales prepare students for real exam scenarios — from pressure ulcer staging to infection management.
Consistent practice not only improves test performance but also strengthens clinical reasoning for real-life nursing situations.