NCWO Wound Assessment 2 — Questions and Answers
Question 1: A Stage 3 pressure injury is defined as:
- Non-blanchable erythema of intact skin
- Partial-thickness loss of skin with exposed dermis
- Full-thickness skin loss without exposed fascia, bone, tendon, or muscle (Correct answer)
- Full-thickness skin and tissue loss with exposed or palpable fascia, bone, or muscle
Correct answer: Full-thickness skin loss without exposed fascia, bone, tendon, or muscle
A Stage 3 pressure injury involves full-thickness skin loss where subcutaneous fat may be visible but fascia, bone, tendon, and muscle are not exposed.
Question 2: The Braden Scale assesses pressure injury risk using which subscales?
- Sensory perception, moisture, activity, mobility, nutrition, friction/shear (Correct answer)
- Age, BMI, diagnosis, mobility, continence, skin condition
- Wound size, depth, exudate, tissue type, periwound skin
- Pain, edema, temperature, color, pulses
Correct answer: Sensory perception, moisture, activity, mobility, nutrition, friction/shear
The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear, with lower scores indicating higher risk.
Question 3: An unstageable pressure injury is characterized by:
- Non-blanchable erythema over a bony prominence
- Full-thickness tissue loss covered by slough or eschar obscuring depth (Correct answer)
- Suspected deep tissue injury with intact skin
- Partial-thickness loss limited to the epidermis
Correct answer: Full-thickness tissue loss covered by slough or eschar obscuring depth
An unstageable pressure injury cannot be staged because the wound bed is obscured by slough or non-removable eschar, preventing depth assessment.
Question 4: Which wound assessment tool uses the acronym TIME to guide debridement decisions?
- Tissue, Infection/Inflammation, Moisture, Edge (Correct answer)
- Temperature, Infection, Measurement, Exudate
- Tissue, Ischemia, Maceration, Edema
- Tunneling, Infection, Moisture, Erosion
Correct answer: Tissue, Infection/Inflammation, Moisture, Edge
The TIME framework stands for Tissue (non-viable), Infection/Inflammation, Moisture imbalance, and Edge (non-advancing), guiding wound bed preparation.
Question 5: A deep tissue pressure injury (DTPI) typically presents as:
- Open wound with yellow slough in the base
- Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration (Correct answer)
- Shallow open wound with a pink or red wound bed
- Full-thickness tissue loss with exposed bone
Correct answer: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration
DTPI appears as persistent non-blanchable discoloration (deep red, maroon, or purple) with intact or non-intact skin resulting from pressure or shear at the tissue-bone interface.
Question 6: Which exudate characteristic raises the strongest concern for wound infection?
- Serous, thin, and clear exudate
- Serosanguineous exudate in moderate amounts
- Purulent, thick, malodorous exudate (Correct answer)
- Sanguineous exudate immediately post-debridement
Correct answer: Purulent, thick, malodorous exudate
Purulent, thick, and malodorous exudate is a classic clinical indicator of wound infection requiring further assessment and possible intervention.
NCWO Wound Assessment 2
A Stage 3 pressure injury is defined as: