Wound Care Certification Exam Wound Care Certification Pressure Injury Prevention 5 — Questions and Answers
Question 1: Which characteristic of a pressure injury MOST strongly supports classifying it as 'unstageable' rather than Stage 3 or 4?
- Presence of serosanguineous exudate
- Wound base is obscured by slough or eschar preventing depth assessment (Correct answer)
- Surrounding skin shows periwound erythema
- The wound has a tunneling tract extending 2 cm
Correct answer: Wound base is obscured by slough or eschar preventing depth assessment
Unstageable pressure injuries cannot be staged because slough or eschar covers the wound base, preventing accurate depth assessment.
Question 2: A patient's sacral wound is documented as having 'epibole.' What does this finding indicate and how does it affect healing?
- New epithelial tissue migrating across the wound bed, indicating healing is progressing normally
- Rolled or thickened wound edges that prevent epithelial migration and impair healing (Correct answer)
- Presence of biofilm on the wound surface requiring antimicrobial dressings
- Granulation tissue overgrowth above the wound surface level
Correct answer: Rolled or thickened wound edges that prevent epithelial migration and impair healing
Epibole refers to rolled, closed wound edges that prevent epithelial cells from migrating across the wound base, stalling healing.
Question 3: Which pressure injury prevention strategy is specifically recommended by NPUAP/EPUAP for patients undergoing MRI scanning?
- Applying a high-density foam overlay inside the MRI scanner bore
- Using MRI-compatible padding on all bony prominences during the scan (Correct answer)
- Repositioning the patient every 15 minutes throughout the scan
- Applying a moisture barrier cream before placing the patient on the MRI table
Correct answer: Using MRI-compatible padding on all bony prominences during the scan
MRI-compatible padding placed at all bony prominences during scanning helps prevent pressure injuries during prolonged immobile positioning in the scanner.
Question 4: A patient with peripheral arterial disease (ABI 0.45) has a suspected pressure injury on the lateral ankle. What assessment finding would MOST influence the wound care approach?
- Wound size greater than 4 cm²
- Severely compromised arterial blood flow limiting healing capacity (Correct answer)
- Presence of moderate yellow slough in the wound bed
- Patient BMI below 20 kg/m²
Correct answer: Severely compromised arterial blood flow limiting healing capacity
An ABI of 0.45 indicates severe arterial insufficiency, which critically limits tissue perfusion and requires vascular evaluation before standard wound care.
Question 5: In the context of pressure injury prevention, what does the term 'turning schedule' documentation PRIMARILY demonstrate?
- That the wound has been measured accurately at each shift
- That evidence-based repositioning interventions were consistently implemented (Correct answer)
- That the patient refused care during the documented period
- That wound dressings were changed according to protocol
Correct answer: That evidence-based repositioning interventions were consistently implemented
Turning schedule documentation provides a legal and clinical record that repositioning — a core prevention intervention — was consistently performed.
Question 6: Which intervention is MOST appropriate to prevent a new pressure injury in a patient who developed a Stage 2 sacral pressure injury during a previous hospitalization?
- Maintain the patient in the same position that was most comfortable during the prior stay
- Implement a comprehensive prevention bundle including risk assessment, skin inspection, pressure redistribution, and repositioning from admission (Correct answer)
- Wait until signs of early skin breakdown appear before initiating preventive measures
- Apply prophylactic wound dressings only after a pressure injury is confirmed
Correct answer: Implement a comprehensive prevention bundle including risk assessment, skin inspection, pressure redistribution, and repositioning from admission
A history of pressure injury is a major risk factor; a full prevention bundle implemented from admission is the most appropriate proactive approach.
Question 7: When assessing a dark-skinned patient for early pressure injury signs, which assessment technique is MOST reliable since erythema may not be visible?
- Relying solely on Braden Scale scores to determine risk
- Assessing for skin temperature changes, firmness, bogginess, and patient-reported pain or discomfort (Correct answer)
- Checking oxygen saturation over the bony prominence with a pulse oximeter
- Comparing skin color only under fluorescent lighting
Correct answer: Assessing for skin temperature changes, firmness, bogginess, and patient-reported pain or discomfort
In dark-skinned patients, palpating for temperature changes, firmness or bogginess, and asking about localized pain are the most reliable early detection methods.
Wound Care Certification Exam Wound Care Certification Pressure Injury Prevention 5
Which characteristic of a pressure injury MOST strongly supports classifying it as 'unstageable' rather than Stage 3 or 4?