Wound Care Certification Wound Assessment and Staging Questions and Answers — Questions and Answers
Question 1: A clinician is assessing a pressure injury on a patient's sacrum. The wound bed is completely obscured by a thick, leathery, black eschar. What is the correct stage for this pressure injury according to the NPIAP guidelines?
- Stage 3
- Stage 4
- Deep Tissue Injury
- Unstageable (Correct answer)
Correct answer: Unstageable
The correct stage is Unstageable. When the base of a full-thickness wound is covered by slough or eschar to the extent that the true depth cannot be determined, it is classified as Unstageable. Once the slough or eschar is removed, the wound will be revealed as either a Stage 3 or Stage 4 pressure injury.
Question 2: During a skin assessment, a nurse notes an area on the patient's heel that is intact, with a localized area of persistent, non-blanchable deep red discoloration. The patient reports pain in the area, which feels boggy upon palpation compared to the surrounding tissue. Which of the following is the most likely classification for this finding?
- Stage 1 Pressure Injury
- Stage 2 Pressure Injury
- Deep Tissue Pressure Injury (Correct answer)
- Venous Stasis Ulcer
Correct answer: Deep Tissue Pressure Injury
This presentation is characteristic of a Deep Tissue Pressure Injury (DTPI). A DTPI involves a localized area of persistent non-blanchable deep red, maroon, or purple discoloration of intact or non-intact skin. Pain and temperature changes often precede the skin color changes, and the tissue may feel boggy or firm.
Question 3: A wound care nurse is assessing a shallow, open ulcer on a patient's ischium. The wound bed is pink and moist, with partial-thickness loss of the dermis. There is no slough, eschar, or granulation tissue visible. Adipose tissue is not exposed. How should this pressure injury be staged?
- Stage 1
- Stage 2 (Correct answer)
- Stage 3
- Unstageable
Correct answer: Stage 2
This wound should be staged as a Stage 2 pressure injury. A Stage 2 injury is defined as partial-thickness skin loss with an exposed dermis. The wound bed is viable, pink or red, moist, and may also present as a serum-filled blister. The absence of slough, eschar, granulation tissue, and exposed adipose tissue are key characteristics of a Stage 2 injury.
Question 4: Which of the following findings would correctly identify a pressure injury as Stage 3?
- Intact skin with non-blanchable erythema.
- Partial-thickness skin loss with exposed dermis.
- Full-thickness skin loss with visible adipose (fat) tissue and granulation tissue. (Correct answer)
- Full-thickness skin and tissue loss with exposed muscle and bone.
Correct answer: Full-thickness skin loss with visible adipose (fat) tissue and granulation tissue.
A Stage 3 pressure injury is characterized by full-thickness loss of skin, where adipose (fat) is visible in the ulcer. Granulation tissue and epibole (rolled wound edges) are often present. Muscle, tendon, or bone are not exposed in a Stage 3 injury.
Question 5: A patient presents with a pressure injury over the coccyx. The assessment reveals full-thickness skin and tissue loss, with directly palpable fascia and muscle in the wound bed. Slough is present in 25% of the wound base, and undermining is noted from the 2 o'clock to 5 o'clock position. This wound would be classified as:
- Stage 2
- Stage 3
- Stage 4 (Correct answer)
- Unstageable
Correct answer: Stage 4
This wound is a Stage 4 pressure injury. The defining characteristic is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While slough is present, it does not obscure the entire wound bed, allowing for determination of the wound's depth and the visualization of underlying structures, making it stageable.
Question 6: A comprehensive wound assessment should include multiple components to guide the plan of care. Which of the following is the MOST complete list of essential assessment components?
- Wound size and color only.
- Location, size, drainage amount, and pain level.
- Anatomical location, dimensions (length, width, depth), wound bed tissue types, drainage characteristics, and condition of the periwound skin. (Correct answer)
- Presence of odor and the patient's nutritional status.
Correct answer: Anatomical location, dimensions (length, width, depth), wound bed tissue types, drainage characteristics, and condition of the periwound skin.
A thorough wound assessment must be comprehensive to be effective. This includes precise anatomical location, measurements (length, width, depth, and any undermining or tunneling), assessment of the tissue types in the wound bed (e.g., granulation, slough, eschar), characteristics of any exudate (amount, color, consistency), and the condition of the skin surrounding the wound (periwound).
Wound Care Certification Wound Assessment and Staging Questions and Answers
A clinician is assessing a pressure injury on a patient's sacrum.
The wound bed is completely obscured by a thick, leathery, black eschar.
What is the correct stage for this pressure injury according to the NPIAP guidelines?