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CWCA (ABWM) practice questions

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Question 1Assessment, Diagnosis, and Documentation of Wounds

A wound is documented as 4 cm × 2 cm × 1 cm. What do these three measurements represent?

  1. Surface area, perimeter, and volume
  2. Width, depth, and tunneling
  3. Length, width, and depth Correct answer.
  4. Length, depth, and undermining

Explanation

Standard wound documentation records three linear dimensions in a fixed order: length (head to toe), width (side to side), and depth (deepest point), all in centimeters. Undermining and tunneling are separate findings recorded with depth plus clock positions. Surface area and volume are calculated values and are not part of the linear dimension set.

Question 2Assessment, Diagnosis, and Documentation of Wounds

The Braden Scale is used in wound care to assess which of the following?

  1. Risk for malnutrition
  2. Severity of a diabetic foot infection
  3. Risk for developing a pressure injury Correct answer.
  4. Risk for falls

Explanation

The Braden Scale scores six subscales - sensory perception, moisture, activity, mobility, nutrition, and friction/shear - to estimate pressure injury risk; lower total scores indicate higher risk. Falls risk is measured with tools such as the Morse Fall Scale. Infection severity and malnutrition are assessed with other instruments and laboratory data.

Question 3Assessment, Diagnosis, and Documentation of Wounds

Wound drainage that is thin, watery, and pale pink in color is documented as:

  1. Purulent
  2. Serous
  3. Sanguineous
  4. Serosanguineous Correct answer.

Explanation

Serosanguineous drainage is a mixture of serum and blood, so it appears thin, watery, and pale pink. Serous drainage is clear or straw-colored plasma, sanguineous drainage is bright red blood, and purulent drainage is thick and opaque.

Question 4Assessment, Diagnosis, and Documentation of Wounds

Moist, beefy red tissue with a granular, pebbled appearance in the wound bed is documented as:

  1. Slough
  2. Eschar
  3. Epithelial tissue
  4. Granulation tissue Correct answer.

Explanation

Granulation tissue is new connective tissue with a capillary bed that gives it a moist, beefy red, pebbled look, and it signals active healing. Slough is soft yellow-tan avascular material, eschar is dry black or brown necrotic tissue, and epithelium is pale pink and shiny.

Question 5Assessment, Diagnosis, and Documentation of Wounds

A pressure injury over the sacrum presents as intact skin with a localized area of non-blanchable erythema. How is this classified?

  1. Deep tissue pressure injury
  2. Unstageable pressure injury
  3. Stage 2 pressure injury
  4. Stage 1 pressure injury Correct answer.

Explanation

Stage 1 pressure injury is defined as intact skin with a localized area of non-blanchable erythema over a bony prominence. Deep tissue pressure injury shows persistent deep purple or maroon discoloration, Stage 2 shows partial-thickness loss with dermis exposed, and unstageable injuries are obscured by slough or eschar.

Question 6Assessment, Diagnosis, and Documentation of Wounds

New, pale pink, shiny tissue that advances inward from the wound margins is documented as:

  1. Epithelialization Correct answer.
  2. Slough
  3. Granulation tissue
  4. Eschar

Explanation

Epithelialization occurs as epithelial cells migrate from the wound edges across the bed, producing thin, pale pink, shiny tissue. Granulation tissue is beefy red and pebbled, slough is yellow-tan and soft, and eschar is leathery black or brown.

Question 7Assessment, Diagnosis, and Documentation of Wounds

Which source is most reliable when assessing the pain associated with a wound?

  1. The size of the wound
  2. The client's self-report using a validated scale Correct answer.
  3. The clinician's estimate of the client's discomfort
  4. The amount of wound exudate

Explanation

Pain is a subjective experience, so the client's self-report using a validated scale is the standard for assessment. Neither wound dimensions nor exudate volume reliably predicts pain intensity, and clinician estimation is an unreliable substitute for self-report.

Question 8Assessment, Diagnosis, and Documentation of Wounds

Which wound location entry is most appropriate for the medical record?

  1. Wound near the ankle bone
  2. 3 cm wound over the right lateral malleolus Correct answer.
  3. Wound below the knee, posterior aspect
  4. Wound on the leg

Explanation

Wound location documentation should specify the body side, the exact anatomical landmark, and the wound size so that another clinician can locate and measure it reproducibly. Vague regional descriptions cannot be verified or compared over time.

Question 9Assessment, Diagnosis, and Documentation of Wounds

Probing a wound reveals 2 cm of undermining extending from 12 o'clock to 3 o'clock. How should this be documented?

  1. 3 cm undermining at 12 o'clock
  2. 2 cm undermining from 12 to 3 o'clock Correct answer.
  3. 2 cm tunnel at 12 o'clock
  4. Undermining of 2 cm² between 12 and 3 o'clock

Explanation

Undermining is recorded as the depth of tissue destruction in centimeters plus the clock positions that bracket the extent of the pocket. The clock face is oriented with 12 o'clock toward the client's head. Tunneling is documented separately, and undermining is a linear depth, not an area.

Question 10Assessment, Diagnosis, and Documentation of Wounds

Which statement best describes tunneling?

  1. A narrow channel extending from the wound edge into surrounding tissue Correct answer.
  2. Tissue loss under intact skin along part of the wound perimeter
  3. Rolled, thickened wound margins that block epithelial migration
  4. A shallow depression confined to the wound bed

Explanation

A tunnel is a narrow, blind-ended channel that extends from the wound edge into adjacent tissue, documented by depth and clock direction. Undermining is tissue loss beneath intact skin around part of the wound perimeter, and epibole refers to rolled wound edges.

Question 11Assessment, Diagnosis, and Documentation of Wounds

An ankle-brachial index of 0.7 in a client with a lower-leg ulcer most likely indicates:

  1. Venous hypertension requiring high-compression bandaging
  2. Normal arterial perfusion of the lower extremity
  3. Ischemia severe enough to require immediate amputation
  4. Peripheral arterial disease that warrants caution with compression Correct answer.

Explanation

An ankle-brachial index below 0.9 indicates arterial insufficiency, and values between 0.5 and 0.9 reflect moderate disease in which compression therapy must be modified or avoided. Normal values fall roughly between 0.9 and 1.3. Critical limb ischemia typically corresponds to an index below 0.4 with rest pain or tissue loss.

Question 12Assessment, Diagnosis, and Documentation of Wounds

Using the Wagner classification for diabetic foot ulcers, a full-thickness ulcer with underlying osteomyelitis is graded as:

  1. Grade 0
  2. Grade 2
  3. Grade 1
  4. Grade 3 Correct answer.

Explanation

In the Wagner system, grade 0 is intact skin in a foot at risk, grade 1 is a superficial ulcer, grade 2 extends to tendon or bone, grade 3 adds deep infection such as osteomyelitis or abscess, grade 4 is partial gangrene, and grade 5 is gangrene of the entire foot.

Question 13Assessment, Diagnosis, and Documentation of Wounds

Which method is recommended for collecting a wound culture from a cleansed wound bed?

  1. Aspirate exudate that has collected in the dressing
  2. Swab the eschar at the center of the wound
  3. Rotate a swab over a 1 cm² area with enough pressure to express tissue fluid Correct answer.
  4. Swab the wound surface lightly without pressure

Explanation

The Levine technique samples a 1 cm² area of cleansed viable wound bed with sufficient pressure to express fluid from the tissue for 5 to 10 seconds, which yields organisms from the tissue rather than the surface. Light surface swabs, drainage from dressings, and eschar cultures recover colonizing flora and mislead therapy.

Question 14Assessment, Diagnosis, and Documentation of Wounds

Which finding is most consistent with a venous insufficiency ulcer?

  1. Punched-out ulcer with a pale wound bed and absent pedal pulses
  2. Deep ulcer over the metatarsal head with surrounding callus
  3. Irregular shallow ulcer near the medial malleolus with surrounding edema Correct answer.
  4. Necrotic ulcer at the lateral malleolus with shiny, hairless skin

Explanation

Venous ulcers typically occur in the gaiter area near the medial malleolus and are shallow with irregular borders, heavy drainage, edema, and hemosiderin staining, with palpable pulses. Arterial ulcers are more often punched out, pale, and painful, and neuropathic ulcers occur over pressure points such as the metatarsal heads.

Question 15Assessment, Diagnosis, and Documentation of Wounds

Rolled, thickened wound edges that fail to migrate over the wound bed are documented as:

  1. Induration
  2. Undermining
  3. Maceration
  4. Epibole Correct answer.

Explanation

Epibole describes wound margins that curl under or become thickened and do not allow epithelial cells to advance, often signaling stalled healing or pressure from the wound edge. Undermining is tissue loss beneath intact periwound skin, maceration is moisture-related skin softening, and induration is firmness of surrounding tissue.

Question 16Assessment, Diagnosis, and Documentation of Wounds

White, soft, wrinkled periwound skin most likely indicates:

  1. Ischemic necrosis
  2. Contact dermatitis
  3. Maceration from excess moisture Correct answer.
  4. Cellulitis

Explanation

Maceration results when periwound skin is exposed to prolonged moisture from exudate, perspiration, or dressing residue, producing white, soft, wrinkled tissue that is vulnerable to breakdown. Cellulitis presents with spreading erythema, warmth, and tenderness, and ischemic tissue is black or necrotic.

Question 17Assessment, Diagnosis, and Documentation of Wounds

The NERDS criteria are used to identify which condition?

  1. Deep infection involving bone
  2. Venous hypertension of the lower leg
  3. Arterial insufficiency of the limb
  4. Superficial critical colonization or local infection Correct answer.

Explanation

NERDS - nonhealing, exudate, red and bleeding tissue, debris, and smell - identifies superficial critical colonization or local infection that may respond to topical antimicrobials. STONEES identifies deeper or spreading infection that warrants systemic antibiotics and further workup.

Question 18Assessment, Diagnosis, and Documentation of Wounds

Which specimen is considered the gold standard for identifying the causative organisms of a wound infection?

  1. Tissue biopsy for quantitative culture Correct answer.
  2. Aspirate of serous exudate
  3. Surface swab of the wound bed
  4. Swab of wound drainage on the dressing

Explanation

Quantitative tissue biopsy gives the most accurate picture of the organisms invading viable tissue and is the reference standard against which other sampling methods are compared. Swabs and exudate specimens are more likely to recover surface colonizers and can lead to inappropriate antibiotic selection.

Question 19Assessment, Diagnosis, and Documentation of Wounds

When taking a photograph of a wound for the medical record, which practice is essential?

  1. Include a measuring device in the frame and keep distance and lighting consistent Correct answer.
  2. Use flash at close range to emphasize tissue color
  3. Photograph only after debridement has been completed
  4. Photograph the wound alone without including surrounding skin

Explanation

Serial wound photographs are useful only when technique is standardized, so the record should include a scale reference and consistent camera distance, angle, and lighting. Including surrounding intact skin provides landmarks for location and comparison over time.

Question 20Assessment, Diagnosis, and Documentation of Wounds

How often should wound measurements and wound status be documented in ongoing care?

  1. At least weekly and with any significant change in condition Correct answer.
  2. Once at the initial assessment, then again only at discharge
  3. Only when the wound appears infected
  4. Every 30 days regardless of care setting

Explanation

Ongoing wound assessment is documented at each visit or dressing change according to setting policy, and formal measurement is expected at least weekly plus whenever the wound changes. A weekly interval allows trends in area and tissue type to be detected before healing stalls.

Question 21Assessment, Diagnosis, and Documentation of Wounds

A rapidly progressive necrotic pressure injury with a pear or butterfly shape develops over the sacrum in an actively dying client with multi-organ failure. This is best identified as:

  1. Moisture-associated skin damage
  2. Deep tissue pressure injury
  3. Kennedy terminal ulcer Correct answer.
  4. Stage 4 pressure injury

Explanation

A Kennedy terminal ulcer appears suddenly, often in the sacrococcygeal or heel area, and progresses rapidly in the final hours to days of life as skin failure accompanies multi-organ decline. It is considered unavoidable and is documented as a distinct entity rather than as a staging failure.

Question 22Assessment, Diagnosis, and Documentation of Wounds

A wound that has been open for many years develops raised, everted margins and a change in the wound bed. Which action is indicated?

  1. Increase the frequency of dressing changes
  2. Obtain a tissue biopsy to rule out malignant transformation Correct answer.
  3. Document the finding and continue the current plan of care
  4. Apply a stronger topical antimicrobial and reassess in 4 weeks

Explanation

Chronic wounds of long duration can undergo malignant transformation, classically squamous cell carcinoma known as a Marjolin ulcer, which presents with raised everted edges and a changing wound bed. Biopsy of the wound edge is required for diagnosis, and treatment is surgical.

Question 23Assessment, Diagnosis, and Documentation of Wounds

Which finding is a component of the STONEES criteria and suggests deep wound infection?

  1. Blanching erythema of the periwound skin
  2. Undermining greater than 2 cm
  3. Slough covering more than half the wound bed
  4. Probe-to-bone during assessment Correct answer.

Explanation

STONEES stands for size increase, temperature elevation, Os (probe-to-bone), new breakdown, erythema and edema, exudate, and smell, and it flags deep or spreading infection requiring systemic treatment. Probe-to-bone is a particularly strong indicator of underlying osteomyelitis in a diabetic foot ulcer.

Question 24Assessment, Diagnosis, and Documentation of Wounds

A sacral pressure injury is covered by a dry, adherent black eschar, and the client has adequate perfusion. How should it be documented?

  1. Stage 4 pressure injury
  2. Stage 2 pressure injury
  3. Deep tissue pressure injury
  4. Unstageable pressure injury Correct answer.

Explanation

When slough or eschar covers the wound bed, the true depth cannot be determined, so the injury is documented as unstageable until the covering tissue is removed. Staging is assigned only after debridement reveals the actual depth of tissue loss.

Question 25Assessment, Diagnosis, and Documentation of Wounds

The PUSH tool score is derived from which three parameters?

  1. Granulation, epithelialization, infection
  2. Pain, odor, periwound status
  3. Depth, tunneling, undermining
  4. Surface area, exudate amount, tissue type Correct answer.

Explanation

The Pressure Ulcer Scale for Healing scores three items: surface area calculated from length times width, exudate amount, and tissue type, producing a total that tracks healing over time. Lower total scores indicate improvement when compared serially.

Question 26Assessment, Diagnosis, and Documentation of Wounds

When measuring a wound, how should the length be determined?

  1. Along the widest horizontal axis regardless of body alignment
  2. By adding the longest and widest dimensions together
  3. Along the head-to-toe axis, using the longest dimension Correct answer.
  4. By tracing the entire wound perimeter with a ruler

Explanation

Length is recorded as the longest measurable dimension, conventionally oriented head-to-toe on the body, with width measured perpendicular to it. Consistent orientation allows serial measurements to be compared over time.

Question 27Assessment, Diagnosis, and Documentation of Wounds

The Braden Scale is used to:

  1. Estimate a client's risk of developing a pressure injury Correct answer.
  2. Score the amount of exudate produced by a wound
  3. Grade the depth of tissue loss in an existing pressure injury
  4. Classify the severity of lower extremity arterial disease

Explanation

The Braden Scale is a risk assessment tool scored from six subscales, with lower total scores indicating higher risk. It predicts risk before injury occurs and does not describe an existing wound.

Question 28Assessment, Diagnosis, and Documentation of Wounds

Which description best fits a Stage 3 pressure injury?

  1. Partial-thickness loss of skin with exposed dermis
  2. Full-thickness loss with palpable bone or exposed fascia in the wound bed
  3. Intact skin with a localized area of non-blanchable erythema
  4. Full-thickness loss exposing subcutaneous fat without bone or tendon Correct answer.

Explanation

Stage 3 involves full-thickness loss of skin in which subcutaneous fat is visible, while deeper structures such as bone, tendon, muscle, or fascia remain unexposed. Slough or eschar may be present but must not obscure the full depth of tissue loss.

Question 29Assessment, Diagnosis, and Documentation of Wounds

Which description characterizes slough?

  1. Firm, dry, black tissue that is adherent to the wound bed
  2. Red, moist, pebbly tissue that bleeds easily when touched
  3. Pale pink, fragile tissue that migrates across the wound surface
  4. Yellow, moist, soft devitalized tissue attached to the wound bed Correct answer.

Explanation

Slough is devitalized tissue that appears yellow to tan, is soft and moist, and clings loosely to the wound bed. Its presence increases bacterial burden and should be documented and managed accordingly.

Question 30Assessment, Diagnosis, and Documentation of Wounds

Clear, pale pink, watery drainage from a wound is documented as:

  1. Purulent
  2. Serosanguineous Correct answer.
  3. Sanguineous
  4. Fibrinous

Explanation

Serosanguineous drainage is a thin mixture of serum and a small amount of blood, giving a pale pink appearance. The terms used for exudate should reflect color and consistency so trends can be tracked accurately.

Question 31Assessment, Diagnosis, and Documentation of Wounds

A chronic wound has shown no reduction in size over 4 weeks of consistent, appropriate treatment. What is the most appropriate interpretation?

  1. The wound is stalled and the plan of care should be reassessed Correct answer.
  2. The wound must be infected and requires an immediate culture
  3. Slow progress is expected and no change in plan is needed
  4. The measurements were probably recorded incorrectly

Explanation

Failure of a wound to show measurable progress over about 4 weeks signals a stalled wound and prompts reassessment of underlying causes such as pressure, perfusion, infection, moisture, or nutrition. Documentation should capture the trend and the revised plan.

Question 32Assessment, Diagnosis, and Documentation of Wounds

Which set of elements does the TIME framework address in wound bed preparation?

  1. Tissue, infection, moisture balance, wound edge Correct answer.
  2. Tissue type, ischemia, measurement, environment
  3. Temperature, infection, moisture, epithelialization
  4. Tissue, inflammation, maceration, exudate

Explanation

TIME stands for Tissue management, Infection or inflammation control, Moisture balance, and Edge of wound advancement. It provides a structured way to identify barriers in the wound bed and match them to interventions.

Question 33Assessment, Diagnosis, and Documentation of Wounds

A sterile cotton-tipped applicator inserted into a diabetic foot ulcer contacts bone. This finding most strongly suggests:

  1. Osteomyelitis that warrants further evaluation Correct answer.
  2. Superficial colonization requiring topical antiseptic
  3. A tunneling wound that needs packing
  4. Venous hypertension underlying the ulcer

Explanation

A positive probe-to-bone test in a diabetic foot ulcer is strongly associated with underlying osteomyelitis and calls for imaging and medical evaluation. The finding should be documented precisely as bone palpated at the wound base.

Question 34Assessment, Diagnosis, and Documentation of Wounds

A client has a lower-leg ulcer with a punched-out margin, a pale wound bed, and little drainage; the foot is cool with weak pedal pulses. These findings are most consistent with:

  1. Arterial insufficiency Correct answer.
  2. Pressure injury
  3. Venous insufficiency
  4. Neuropathic disease

Explanation

Punched-out margins, a pale dry base, poor drainage, cool skin, and diminished pulses reflect reduced arterial perfusion. These features help distinguish arterial ulcers from venous and neuropathic ulcers before compression or debridement decisions are made.

Question 35Assessment, Diagnosis, and Documentation of Wounds

Odor is noted when a dressing is removed. What is the best way to assess it?

  1. Record the odor exactly as first perceived on dressing removal
  2. Cleanse the wound and reassess before documenting odor Correct answer.
  3. Assume odor is present only if drainage is purulent
  4. Ask the client to describe the odor of the old dressing

Explanation

Odor from a soiled dressing may reflect dressing residue or stale exudate rather than the wound itself, so the wound should be cleansed and reassessed before odor is documented. This avoids attributing a dressing-related smell to wound infection.

Question 36Assessment, Diagnosis, and Documentation of Wounds

Which statement best describes the Bates-Jensen Wound Assessment Tool?

  1. It scores multiple wound characteristics over time Correct answer.
  2. It assigns a stage to pressure injuries based on depth
  3. It predicts the risk of developing a pressure injury
  4. It measures wound surface area in square centimeters

Explanation

The Bates-Jensen tool rates a range of wound characteristics such as size, depth, edges, necrotic tissue, exudate, and periwound skin on a numeric scale. Serial total scores allow healing progress or deterioration to be tracked and compared.

Question 37Assessment, Diagnosis, and Documentation of Wounds

Which finding is characteristic of a deep tissue pressure injury?

  1. Skin that is intact with blanching erythema that resolves with pressure relief
  2. A blister filled with clear serous fluid over a bony prominence
  3. Intact skin with a persistent deep purple or maroon area Correct answer.
  4. A shallow open ulcer with a red-pink wound bed

Explanation

A deep tissue pressure injury presents as intact or blistered skin with persistent, non-blanchable deep purple or maroon discoloration from damage to underlying tissue. It may evolve rapidly to reveal the true extent of injury.

Question 38Assessment, Diagnosis, and Documentation of Wounds

Pressure injuries on mucous membranes are handled how in documentation?

  1. They are reported as mucosal pressure injuries and are not staged Correct answer.
  2. They are staged only when the tissue loss is full thickness
  3. They are excluded from the assessment because mucosa cannot be injured
  4. They are staged using the same 1-to-4 system as skin injuries

Explanation

Mucous membrane pressure injuries are documented by location and cause but are not assigned a stage, because mucous membranes lack the skin layers the staging system depends on. Common sources include medical devices such as respiratory or feeding tubes.

Question 39Assessment, Diagnosis, and Documentation of Wounds

A wound is described using the red-yellow-black system. A wound bed that is predominantly black indicates:

  1. Necrotic tissue requiring debridement Correct answer.
  2. Clean granulation tissue
  3. Newly formed epithelium
  4. Superficial slough only

Explanation

In the red-yellow-black system, black represents necrotic, devitalized tissue such as eschar that must be removed before healing can progress. Red indicates granulation and yellow indicates slough or fibrous tissue.

Question 40Assessment, Diagnosis, and Documentation of Wounds

When documenting wound status, which entry is most appropriate?

  1. 100% granulation; 0.4 cm deep; moderate drainage Correct answer.
  2. Wound is about the same as before
  3. Wound is healing nicely with no concerns
  4. Wound looks better than last week

Explanation

Appropriate documentation uses objective, measurable descriptors of the wound bed, size, and exudate so that future clinicians can detect change. Subjective impressions and vague comparisons are not reliable for tracking progress.

Question 41Assessment, Diagnosis, and Documentation of Wounds

A neuropathic (diabetic) foot ulcer most typically occurs:

  1. Over a plantar metatarsal head or the toes Correct answer.
  2. On the medial malleolus of the ankle
  3. Along the posterior calf
  4. Over the sacrum in bedbound clients

Explanation

Loss of protective sensation allows repetitive pressure at high-load areas of the foot, so neuropathic ulcers usually form over plantar metatarsal heads, the toes, or the heel. The surrounding skin is often callused.

Question 42Assessment, Diagnosis, and Documentation of Wounds

The 10-g Semmes-Weinstein monofilament is used in a foot assessment to:

  1. Detect loss of protective sensation Correct answer.
  2. Screen for venous valve incompetence
  3. Estimate arterial perfusion of the toes
  4. Measure the depth of a plantar ulcer

Explanation

Failure to perceive the 10-g monofilament at designated plantar sites indicates loss of protective sensation, a major risk factor for neuropathic ulceration. Findings are documented site by site so risk can be communicated and preventive care planned.

Question 43Assessment, Diagnosis, and Documentation of Wounds

An ankle-brachial index of 1.4 in a client with diabetes and a foot ulcer most likely indicates:

  1. Normal arterial flow in the lower extremity
  2. Calcified, non-compressible arteries Correct answer.
  3. Venous ulceration of the ankle
  4. Mild peripheral arterial disease

Explanation

An ankle-brachial index above about 1.3 suggests arteries that do not compress because of medial calcification, common in diabetes and chronic kidney disease. In such cases Doppler waveform analysis or toe pressures are needed to assess perfusion.

Question 44Assessment, Diagnosis, and Documentation of Wounds

Which statement best defines a Stage 4 pressure injury?

  1. Partial-thickness loss of skin with exposed dermis and no slough
  2. Full-thickness loss with visible subcutaneous fat and granulation tissue
  3. Full-thickness loss with exposed fascia, muscle, tendon, or bone Correct answer.
  4. Intact skin with non-blanchable erythema over a bony prominence

Explanation

A Stage 4 injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, cartilage, or bone. Slough or eschar may be present but does not obscure the exposed deep structures.

Question 45Wound Bed Preparation and Local Wound Management

In the TIME framework for wound bed preparation, what does the letter T represent?

  1. Temperature control of the wound bed
  2. Total bacterial burden of the wound
  3. Tensile strength of the wound edges
  4. Tissue management Correct answer.

Explanation

TIME stands for Tissue management, Infection or inflammation control, Moisture balance, and Edge advancement. The T refers to removing non-viable tissue and biofilm so the wound bed can progress toward healing.

Question 46Wound Bed Preparation and Local Wound Management

Which debridement method relies on the body's own enzymes and moisture to soften and separate non-viable tissue?

  1. Sharp debridement with a scalpel
  2. Mechanical debridement with wet-to-dry gauze
  3. Autolytic debridement under an occlusive dressing Correct answer.
  4. Enzymatic debridement with collagenase

Explanation

Autolytic debridement uses the wound's own macrophages and enzymes under a moist, occlusive environment to liquefy necrotic tissue. It is the gentlest selective method and is limited by the wound's own healing capacity.

Question 47Wound Bed Preparation and Local Wound Management

Which dressing is most appropriate for a heavily exuding cavity wound?

  1. Semipermeable transparent film dressing
  2. Hydrocolloid wafer with tapered edges
  3. Calcium alginate rope Correct answer.
  4. Hydrogel sheet

Explanation

Alginate dressings absorb large volumes of exudate and form a gel that conforms to cavity wounds, making them suitable for packing moderately to heavily draining wounds. They require adequate exudate to function and should be changed when the gel is saturated.

Question 48Wound Bed Preparation and Local Wound Management

Which solution is generally the cleanser of choice for a clean, granulating chronic wound?

  1. Sodium hypochlorite (Dakin solution)
  2. Hydrogen peroxide 3%
  3. Sterile 0.9% sodium chloride Correct answer.
  4. Povidone-iodine scrub

Explanation

Normal saline is isotonic, non-cytotoxic, and adequate for removing surface debris without injuring newly formed tissue. Routine use of cytotoxic antiseptics is reserved for specific indications such as clinical infection.

Question 49Wound Bed Preparation and Local Wound Management

What irrigation pressure range is considered safe and effective for cleansing most wounds?

  1. 4 to 15 psi Correct answer.
  2. 25 to 40 psi
  3. 1 to 2 psi
  4. 50 to 70 psi

Explanation

Pressures of roughly 4 to 15 psi, delivered with a 35-mL syringe and 19-gauge needle, remove debris and bacteria while limiting trauma to the wound bed. Higher pressures drive bacteria into tissue and damage new cells.

Question 50Wound Bed Preparation and Local Wound Management

Dry, hard, black or brown adherent tissue covering a wound bed is best described as:

  1. Eschar Correct answer.
  2. Maceration
  3. Slough
  4. Granulation tissue

Explanation

Eschar is devitalized tissue that is dry, firm, and darkly colored, and it frequently requires debridement to allow healing. It differs from slough, which is soft and moist.