CWS Wound Assessment and Dressing Selection Questions and Answers Flashcards

Which clinical sign best differentiates wound infection from normal inflammation in a healing wound?

Answer: Increasing pain, warmth, erythema with purulent exudate beyond the wound margin

Classic signs of wound infection include increased pain, warmth, spreading erythema, and purulent discharge, distinguishing it from the expected inflammatory phase.

What is the recommended method for measuring wound size in clinical documentation?

Answer: Length × width × depth in centimeters using the head-to-toe axis orientation

Standard practice is to measure the longest length (head-to-toe axis), widest width (perpendicular), and deepest depth in centimeters.

Foam dressings are most appropriate for which type of wound?

Answer: Moderate-to-heavily exudating wounds requiring cushioning and absorption

Foam dressings absorb moderate-to-heavy exudate, provide thermal insulation and cushioning, and maintain a moist environment without maceration.

What does periwound maceration indicate, and how should it be managed?

Answer: Excessive moisture causing skin breakdown; manage by switching to a more absorbent dressing and applying a skin barrier

Maceration is caused by prolonged moisture exposure to periwound skin; treatment involves increasing dressing absorbency and protecting the skin with a barrier product.

Which tool uses a color-coded visual guide to classify wound tissue types (black, yellow, red, pink)?

Answer: RYB (Red-Yellow-Black) wound color classification

The Red-Yellow-Black (RYB) color classification system provides a quick visual framework for identifying the predominant wound tissue and guiding dressing selection.

A diabetic foot ulcer classified as Wagner Grade 2 has which defining characteristic?

Answer: Deep ulcer penetrating to tendon, capsule, or bone without osteomyelitis

Wagner Grade 2 indicates a deeper ulcer reaching tendon, joint capsule, or bone, but without evidence of osteomyelitis or abscess.