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WCC practice questions

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Question 1Skin anatomy, physiology, and the phases of wound healing

Which sequence lists the layers of the epidermis from deepest to most superficial?

  1. Stratum corneum, stratum granulosum, stratum spinosum, stratum basale
  2. Stratum basale, stratum spinosum, stratum granulosum, stratum corneum Correct answer.
  3. Stratum granulosum, stratum basale, stratum corneum, stratum spinosum
  4. Stratum spinosum, stratum corneum, stratum basale, stratum granulosum

Explanation

The epidermis is a stratified squamous epithelium in which keratinocytes proliferate in the basal layer and mature progressively as they move outward. The normal sequence is basale, spinosum, granulosum, then corneum, with a stratum lucidum added only in thick glabrous skin.

Question 2Skin anatomy, physiology, and the phases of wound healing

Which epidermal cell is responsible for synthesizing melanin pigment?

  1. The melanocyte Correct answer.
  2. The keratinocyte
  3. The Merkel cell
  4. The Langerhans cell

Explanation

Melanocytes reside in the basal layer and produce melanin in melanosomes, which they transfer to surrounding keratinocytes to protect DNA from ultraviolet damage. The other epidermal cells perform structural, immune, or sensory roles.

Question 3Skin anatomy, physiology, and the phases of wound healing

What is the principal function of the stratum corneum?

  1. Transduction of fine touch stimuli
  2. Synthesis of vitamin D precursors
  3. Secretion of sebum onto the surface
  4. Barrier to water loss and infection Correct answer.

Explanation

The stratum corneum consists of flattened corneocytes embedded in a lipid matrix and forms the main permeability barrier that limits transepidermal water loss and excludes microorganisms and irritants. Its integrity depends on corneocyte proteins and intercellular lipids.

Question 4Skin anatomy, physiology, and the phases of wound healing

Eccrine sweat glands contribute most directly to which cutaneous function?

  1. Synthesis of collagen bundles
  2. Storage of subcutaneous fat
  3. Cutaneous immune surveillance
  4. Thermoregulation by evaporative cooling Correct answer.

Explanation

Eccrine glands secrete a watery fluid onto the skin surface, and evaporation of that fluid dissipates heat, making them the principal effector of human thermoregulation. Their coiled secretory portion lies deep in the dermis with a duct opening directly onto the surface.

Question 5Skin anatomy, physiology, and the phases of wound healing

Which event characterizes the hemostasis phase of wound healing?

  1. Platelet aggregation and fibrin clot formation Correct answer.
  2. Neutrophil infiltration and bacterial killing
  3. Collagen remodeling and scar maturation
  4. Fibroblast proliferation and new vessel growth

Explanation

Immediately after injury, exposed subendothelial tissue triggers platelet adhesion and aggregation, and the coagulation cascade converts fibrinogen to fibrin to form a clot. This clot provides provisional hemostasis and a scaffold for the cells that follow.

Question 6Skin anatomy, physiology, and the phases of wound healing

The surface pH of healthy adult skin typically falls within which range?

  1. 8.0 to 9.0
  2. 6.5 to 7.5
  3. 4.5 to 5.5 Correct answer.
  4. 1.0 to 2.5

Explanation

Intact adult skin is mildly acidic, usually quoted around pH 4.5 to 5.5, a state maintained by sweat, sebum breakdown products, and filaggrin-derived acids. This acid mantle favors barrier lipid processing and discourages colonization by pathogenic bacteria.

Question 7Skin anatomy, physiology, and the phases of wound healing

What is a primary role of the subcutaneous fat layer?

  1. Insulation, energy storage, and cushioning Correct answer.
  2. Production of melanin pigment
  3. Antigen presentation to T lymphocytes
  4. Formation of the waterproof keratin barrier

Explanation

The subcutaneous layer is dominated by adipose tissue and loose connective tissue with larger vessels and nerves. It provides thermal insulation, an energy reserve, and mechanical protection for underlying structures.

Question 8Skin anatomy, physiology, and the phases of wound healing

Which collagen type is most abundant in the normal dermis?

  1. Type IV
  2. Type I Correct answer.
  3. Type III
  4. Type II

Explanation

The reticular dermis is composed predominantly of type I collagen, which forms thick bundles that give skin its tensile strength, with type III collagen present in smaller amounts. Type IV collagen is largely restricted to basement membranes and type II collagen predominates in cartilage.

Question 9Skin anatomy, physiology, and the phases of wound healing

In normal skin, complete turnover of the epidermis from basal layer to desquamation takes approximately how long?

  1. 60 days
  2. 120 days
  3. 7 days
  4. 28 days Correct answer.

Explanation

Keratinocytes are produced in the basal layer and migrate outward over roughly four weeks before being shed from the stratum corneum. This turnover rate accelerates markedly in hyperproliferative states such as psoriasis.

Question 10Skin anatomy, physiology, and the phases of wound healing

During the inflammatory phase of wound healing, which sequence of cell infiltration is typical?

  1. Fibroblasts first, then neutrophils
  2. Macrophages first, then neutrophils
  3. Neutrophils first, then macrophages Correct answer.
  4. Lymphocytes first, then eosinophils

Explanation

Neutrophils arrive earliest, peaking in the first one to two days to debride bacteria, and are then superseded by macrophages, which dominate from roughly 48 to 72 hours and orchestrate the transition to repair. Macrophages also release growth factors that recruit fibroblasts and endothelial cells.

Question 11Skin anatomy, physiology, and the phases of wound healing

Granulation tissue is best described as which combination?

  1. Dense scar collagen with few vessels
  2. New capillaries, fibroblasts, collagen Correct answer.
  3. Fibrin mesh with trapped erythrocytes
  4. Keratinized epithelium over fibrin

Explanation

Granulation tissue fills open wounds and consists of proliferating fibroblasts, newly formed capillary loops, inflammatory cells, and loose newly deposited collagen, giving it a red, granular appearance. It later matures into paler scar tissue as vascularity decreases and collagen is remodeled.

Question 12Skin anatomy, physiology, and the phases of wound healing

Which cell type is chiefly responsible for wound contraction?

  1. Endothelial cells
  2. Keratinocytes
  3. Myofibroblasts Correct answer.
  4. Neutrophils

Explanation

Myofibroblasts are fibroblasts that acquire smooth-muscle-like contractile features and generate the forces that pull wound edges together, reducing the surface area needing epithelial coverage. Excessive contraction across joints can produce contractures.

Question 13Skin anatomy, physiology, and the phases of wound healing

A heavily contaminated wound with substantial tissue loss is left open to fill with granulation tissue before it closes. This represents healing by:

  1. Primary intention
  2. Regeneration without scar formation
  3. Delayed primary closure
  4. Secondary intention Correct answer.

Explanation

Healing by secondary intention occurs when wound edges cannot be approximated, so the defect fills with granulation tissue and contracts before epithelialization from the margins, leaving a larger scar. Primary intention applies to clean, surgically apposed edges, and delayed primary closure refers to suturing a wound after a period of open management.

Question 14Skin anatomy, physiology, and the phases of wound healing

Vitamin C is required for wound healing primarily because it:

  1. Triggers platelet aggregation at the wound site
  2. Acts as the main substrate for fibrin formation
  3. Supplies calcium for keratinocyte differentiation
  4. Is a cofactor for prolyl hydroxylase Correct answer.

Explanation

Ascorbate is a cofactor for prolyl and lysyl hydroxylase, enzymes that hydroxylate collagen precursor chains so that stable triple helices and cross-links can form. Deficiency produces weak, poorly cross-linked collagen and impaired wound strength.

Question 15Skin anatomy, physiology, and the phases of wound healing

Which statement correctly describes Langerhans cells?

  1. They secrete sebum into the follicle
  2. They are mechanoreceptors of the basal layer
  3. They synthesize melanin for keratinocytes
  4. They are antigen-presenting cells of the epidermis Correct answer.

Explanation

Langerhans cells are dendritic, bone-marrow-derived cells scattered through the epidermis that capture antigen and migrate to regional lymph nodes to present it to T lymphocytes. They form part of the skin's adaptive immune surveillance.

Question 16Skin anatomy, physiology, and the phases of wound healing

Sebaceous gland secretory activity is most directly stimulated by which factor?

  1. Thyroid hormone
  2. Androgens Correct answer.
  3. Estrogen
  4. Insulin

Explanation

Sebaceous glands are holocrine glands whose sebum output is driven mainly by androgens, which explains the increase in sebum production at puberty and in androgen-excess states. Sebum contributes to the surface lipid film and the acid mantle.

Question 17Skin anatomy, physiology, and the phases of wound healing

The dermal papillae primarily serve to:

  1. Increase dermal-epidermal interface area Correct answer.
  2. Provide a physical barrier to ultraviolet light
  3. Generate the pigment responsible for skin colour
  4. Anchor hair follicles within subcutaneous fat

Explanation

Interdigitating dermal papillae and epidermal rete ridges greatly expand the interface between the avascular epidermis and the vascular dermis. This improves nutrient and oxygen exchange and strengthens mechanical adhesion between the two layers.

Question 18Skin anatomy, physiology, and the phases of wound healing

Zinc deficiency delays wound healing mainly because zinc:

  1. Serves as an enzymatic cofactor in tissue repair Correct answer.
  2. Is required for melanin synthesis
  3. Forms the backbone of the fibrin clot
  4. Is the main structural protein of the dermis

Explanation

Zinc is a cofactor for numerous enzymes involved in DNA synthesis, cell proliferation, and protein synthesis, all of which are required for repair. Deficiency therefore slows epithelialization and collagen deposition.

Question 19Skin anatomy, physiology, and the phases of wound healing

The dermal-epidermal basement membrane is composed mainly of which molecules?

  1. Keratin and filaggrin
  2. Type I collagen and elastin
  3. Type IV collagen and laminin Correct answer.
  4. Fibronectin and fibrinogen

Explanation

The basement membrane zone is built from type IV collagen forming a network and laminin anchoring epithelial cells via hemidesmosomes, along with other glycoproteins and proteoglycans. It provides adhesion and acts as a filtration and signaling interface.

Question 20Skin anatomy, physiology, and the phases of wound healing

Approximately what maximum percentage of unwounded skin tensile strength does a mature scar attain?

  1. About 80% Correct answer.
  2. About 20%
  3. About 100%
  4. About 50%

Explanation

Wound strength rises rapidly over the first weeks but a mature scar plateaus at roughly 70 to 80 percent of the tensile strength of uninjured skin because remodeled scar collagen is less organized than normal dermal collagen. Strength never returns fully to baseline.

Question 21Skin anatomy, physiology, and the phases of wound healing

During the maturation phase, which change best characterizes collagen in the healing wound?

  1. Elastin replaces collagen as the principal scar protein
  2. Type IV collagen accumulates as the dominant scar protein
  3. Type III collagen is progressively replaced by type I collagen Correct answer.
  4. Type I collagen is progressively replaced by type III collagen

Explanation

Early wound matrix is rich in type III collagen, which is gradually degraded and replaced by thicker type I collagen bundles that become increasingly cross-linked and aligned. This remodeling increases tensile strength while reducing scar thickness and vascularity.

Question 22Skin anatomy, physiology, and the phases of wound healing

The proliferative phase of wound healing typically begins at about which time after injury?

  1. Day 14 to 21
  2. Within the first hour
  3. Day 3 to 4 Correct answer.
  4. Week 6 to 8

Explanation

After the early inflammatory response, fibroblasts migrate into the wound and angiogenesis begins around day three to four, marking the start of the proliferative phase. This phase, which includes granulation tissue formation, contraction, and re-epithelialization, then overlaps with the remodeling phase.

Question 23Skin anatomy, physiology, and the phases of wound healing

Re-epithelialization of a deep partial-thickness wound is accelerated mainly because:

  1. Circulating stem cells colonize the wound surface within hours
  2. Keratinocytes divide faster in an anaerobic environment
  3. Epithelial cells migrate from surviving hair follicles and glands Correct answer.
  4. The fibrin eschar acts as a scaffold for epithelial cells

Explanation

In partial-thickness injuries, epithelial cells surviving in hair follicle infundibula and sweat gland ducts provide additional sources of keratinocytes that migrate across the moist wound bed alongside cells from the wound margins. The more appendages that survive, the faster the surface is restored.

Question 24Skin anatomy, physiology, and the phases of wound healing

Which mechanism best explains why chronic wounds often remain unhealed despite adequate nutrition?

  1. Elevated protease activity degrades growth factors and matrix Correct answer.
  2. Hemostasis cannot occur in a chronic wound
  3. Fibroblasts permanently lose the ability to divide
  4. Keratinocytes migrate too rapidly and cover the wound bed

Explanation

Chronic wounds commonly show an exaggerated inflammatory state with high levels of matrix metalloproteinases that destroy newly formed matrix and growth factors. This catabolic environment prevents the wound from progressing out of inflammation into productive repair.

Question 25Wound assessment, measurement, and documentation

A nurse measures an irregularly shaped sacral wound for the weekly assessment. Which technique produces the most reproducible serial measurement?

  1. Measure the longest head-to-toe dimension and the greatest width perpendicular to it Correct answer.
  2. Trace the wound on a grid and count only the squares that are completely covered
  3. Measure the distance around the wound margin with a flexible tape
  4. Measure the longest diagonal across the wound at whatever angle looks largest

Explanation

Wound length is recorded as the longest dimension oriented head to toe, and width as the greatest dimension perpendicular to that line. This fixed orientation allows another clinician to reproduce the measurement and makes serial values comparable over time.

Question 26Wound assessment, measurement, and documentation

Which wound bed tissue appears beefy red, moist, and finely granular, and signals that healing is progressing?

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

Explanation

Granulation tissue forms as new capillaries and connective tissue fill the wound bed, giving it a red, moist, pebbled appearance. Its presence generally indicates an active healing response in a clean wound bed.

Question 27Wound assessment, measurement, and documentation

Clear drainage with a pale pink tinge that is thin and watery is documented as:

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

Explanation

Serosanguineous exudate is a mixture of serum and small amounts of blood, giving a thin, pale pink to light red appearance. Pure sanguineous drainage is frankly bloody, and serous drainage is clear to straw colored.

Question 28Wound assessment, measurement, and documentation

The term for tissue loss that extends beneath intact skin at the wound margin is:

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

Explanation

Undermining is tissue destruction that extends under the wound edge and beneath intact periwound skin, often forming a lip. It is measured by depth and documented by the clock positions involved.

Question 29Wound assessment, measurement, and documentation

A wound is documented as 4.0 cm by 2.0 cm by 0.5 cm. What does the third value represent?

  1. Depth Correct answer.
  2. Length
  3. Width
  4. Surface area

Explanation

Wound dimensions are conventionally recorded as length by width by depth, all in centimeters. Depth is measured at the deepest point of the wound bed relative to the level of the skin surface.

Question 30Wound assessment, measurement, and documentation

Which element most improves the description of a wound's location in the medical record?

  1. Anatomic landmarks that identify the site precisely Correct answer.
  2. The name of the clinician who changed the dressing previously
  3. The date the wound was first photographed
  4. The patient's room and bed number

Explanation

Location is documented using body part plus anatomic landmarks, such as the right lateral malleolus or the coccyx 2 cm above the anal verge. Room numbers and shift details change and do not identify the site reliably.

Question 31Wound assessment, measurement, and documentation

Which tissue type is black or brown, leathery, and firmly adherent to the wound base?

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

Explanation

Eschar is dry, thick, leathery necrotic tissue that is black, brown, or tan and adheres firmly to the wound bed. It must generally be debrided before the wound can heal or be accurately staged.

Question 32Wound assessment, measurement, and documentation

The PUSH tool is designed to:

  1. Quantify wound-related pain on a numeric scale
  2. Classify the stage of a diabetic foot ulcer
  3. Estimate the patient's risk of developing a pressure injury
  4. Score pressure injury healing using surface area, exudate amount, and tissue type Correct answer.

Explanation

The PUSH tool scores three wound characteristics: surface area, exudate amount, and tissue type, producing a total that is tracked over time. A falling total reflects healing progress for pressure injuries.

Question 33Wound assessment, measurement, and documentation

A wound has tunneling at the 3 o'clock position. What is the best way for the nurse to measure and document it?

  1. Record only the clock position, since tracts cannot be measured directly
  2. Insert a measured cotton-tipped applicator to the end of the tract and record the depth with the clock position Correct answer.
  3. Flush the tract with saline and record the volume that was instilled
  4. Estimate the tract length visually and add it to the wound width

Explanation

Tunneling is measured by gently advancing a measured swab to the base of the tract, then reading the distance at the skin surface. The depth is documented together with the clock position of the tract opening.

Question 34Wound assessment, measurement, and documentation

Which set of findings defines a Stage 1 pressure injury?

  1. Intact skin with a persistent deep purple area and a blood-filled blister
  2. Partial-thickness skin loss with a shallow open ulcer and no slough
  3. Intact skin with a localized area of nonblanchable erythema Correct answer.
  4. Full-thickness loss with visible subcutaneous fat

Explanation

A Stage 1 pressure injury involves intact skin with a localized area of nonblanchable erythema, typically over a bony prominence. Because the skin is intact, the injury is identified by color change that does not blanch, not by an open wound.

Question 35Wound assessment, measurement, and documentation

A sacral wound in a bedbound patient has a base entirely covered by adherent yellow slough and dark eschar. How should it be staged?

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

Explanation

When slough or eschar obscures the full extent of tissue loss, the pressure injury cannot be staged until the covering is removed and the wound base can be seen. It is documented as unstageable in the meantime.

Question 36Wound assessment, measurement, and documentation

White, softened, wrinkled tissue at the wound margins is documented as:

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

Explanation

Maceration results from prolonged moisture exposure and appears as pale, softened, wrinkled periwound skin. It is documented because it signals the need for better moisture control to prevent extension of tissue damage.

Question 37Wound assessment, measurement, and documentation

Which technique yields the most useful culture specimen from an open, granulating wound?

  1. Collect the pooled exudate sitting at the wound margin
  2. Aspirate fluid from an intact blister over the wound
  3. Swab the largest patch of eschar in the wound bed
  4. Swab a 1-cm area of clean granulation tissue with enough pressure to express fluid Correct answer.

Explanation

The Levine technique samples viable tissue by pressing a swab over a defined area of clean granulation until tissue fluid is expressed. Swabbing necrotic tissue or pooled surface exudate yields colonizing organisms rather than the pathogens driving infection.

Question 38Wound assessment, measurement, and documentation

For a healing pressure injury in a long-term care resident, wound status should be formally reassessed and documented at least:

  1. Every shift
  2. Monthly
  3. Weekly and whenever the clinical condition or treatment plan changes Correct answer.
  4. Once every 3 months

Explanation

Formal wound measurement and documentation are typically completed at least weekly, with additional assessment whenever the wound deteriorates or the treatment changes. More frequent dressing-related inspection occurs with each dressing change but does not replace the formal measurement.

Question 39Wound assessment, measurement, and documentation

Which practice makes serial wound measurements comparable between clinicians?

  1. Using the same method, patient position, and anatomic landmarks at every assessment Correct answer.
  2. Measuring only after the dressing has been off for at least 30 minutes
  3. Rounding all dimensions to the nearest 5 cm
  4. Alternating measurement methods to reduce observer bias

Explanation

Consistency in technique, positioning, and landmarks is what allows two measurements weeks apart to be meaningfully compared. Changing method or position introduces variation that can be mistaken for healing or deterioration.

Question 40Wound assessment, measurement, and documentation

Undermining extends from 6 o'clock to 9 o'clock to a depth of 2 cm. How should this be documented?

  1. A 2 cm sinus tract at the 9 o'clock position
  2. A 3 cm wound width at the wound base
  3. 3 cm of tunneling beginning at 6 o'clock
  4. Undermining from 6 to 9 o'clock, 2 cm deep Correct answer.

Explanation

Undermining is documented as the clock positions it spans plus the depth measured at the deepest point. The span of clock positions describes the extent along the margin, while the depth describes how far it reaches under the skin.

Question 41Wound assessment, measurement, and documentation

Rolled, thickened wound edges that can block epithelial migration are documented as:

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

Explanation

Epibole describes wound margins that have rolled inward and thickened, which prevents new epithelium from advancing across the wound bed. It is often addressed by debriding or cauterizing the rim so healing can resume.

Question 42Wound assessment, measurement, and documentation

Which set of terms is appropriate for documenting the amount of wound exudate?

  1. Small, medium, huge, massive
  2. Grade I, Grade II, Grade III, Grade IV
  3. Trace, mild, severe, critical
  4. None, minimal, moderate, copious Correct answer.

Explanation

Exudate amount is documented with a small set of standardized descriptors such as none, minimal, moderate, or copious. Using consistent terms across clinicians allows trends to be recognized and compared over time.

Question 43Wound assessment, measurement, and documentation

Which practice improves the clinical usefulness of wound photographs?

  1. Photographing the wound with no scale or label in the frame
  2. Using a direct flash aimed straight at the wound surface every time
  3. Substituting the photograph for measurement at each visit
  4. Including a measuring guide in the frame and keeping camera distance and angle consistent between visits Correct answer.

Explanation

A visible scale and consistent framing let clinicians judge true size and compare images taken at different visits. Direct flash creates glare and color distortion that can obscure tissue type and exudate.

Question 44Wound assessment, measurement, and documentation

A nurse realizes that a wound assessment performed at 0800 was never charted. What is the appropriate action?

  1. Back-date the entry to 0800 as though it had been written then
  2. Omit the entry because the moment for documenting it has passed
  3. Write a late entry with the actual date and time of writing and identify it as a late entry Correct answer.
  4. Enter the findings in narrative notes without any date or time

Explanation

A late entry is permissible when it is clearly labeled, carries the actual time it is written, and refers to the time the care occurred. Altering times or omitting the record compromises the accuracy and legal integrity of the chart.

Question 45Wound assessment, measurement, and documentation

A wound measured 5 cm by 4 cm at baseline and 4 cm by 3 cm at the 4-week reassessment. What is the percentage reduction in surface area?

  1. 8%
  2. 40% Correct answer.
  3. 60%
  4. 25%

Explanation

Baseline area is 20 cm² and the current area is 12 cm², a decrease of 8 cm². Dividing the change by the baseline area (8 ÷ 20) gives a 40% reduction, which is on track for expected healing.

Question 46Wound assessment, measurement, and documentation

Which statement accurately describes a deep tissue pressure injury?

  1. It is staged as Stage 1 until eschar forms
  2. It blanches readily when light finger pressure is applied
  3. It presents as intact or non-intact skin with a persistent deep purple or maroon area or a blood-filled blister Correct answer.
  4. It always presents as an open ulcer with exposed fascia or muscle

Explanation

A deep tissue pressure injury results from damage to deeper structures while the surface may remain intact, appearing as a persistent deep purple or maroon area or a blood-filled blister. It may evolve rapidly to reveal full-thickness loss even with optimal care.

Question 47Wound assessment, measurement, and documentation

A Stage 3 pressure injury has completely re-epithelialized. How should it be documented in the current assessment?

  1. Stage 1 pressure injury
  2. Stage 0 pressure injury
  3. Simply as intact skin with no pressure injury history
  4. Healed Stage 3 pressure injury Correct answer.

Explanation

Pressure injury staging reflects the deepest tissue level ever exposed and is not downgraded as the wound improves. A closed injury is documented as a healed Stage 3 pressure injury so the history remains accurate.

Question 48Wound assessment, measurement, and documentation

A nurse measures the depth of a deep sacral ulcer. Which technique is most accurate?

  1. Inserting a measured swab perpendicular to the skin surface to the deepest point and reading the centimeters at skin level Correct answer.
  2. Estimating depth by comparing the wound with a familiar object such as a coin
  3. Laying a flexible tape across the wound surface and reading the deepest visible point
  4. Calculating depth by dividing wound area by wound length

Explanation

Depth is measured by gently inserting a measured swab to the deepest point while holding it perpendicular to the skin, then noting where the skin surface meets the swab. This avoids angling the swab and overestimating depth.

Question 49Wound assessment, measurement, and documentation

Which cluster of findings in a previously stable wound most suggests critical colonization rather than normal healing?

  1. A pale pink wound bed with a new 1 mm rim of epithelium
  2. New increased pain, friable bright red tissue that bleeds easily, and a rise in exudate Correct answer.
  3. A small amount of serous drainage on the dressing on postoperative day 2
  4. A 20% reduction in wound area over 3 weeks

Explanation

Increasing pain, friable granulation that bleeds with minimal contact, and escalating exudate are subtle signs of increasing bacterial burden before frank infection appears. These findings warrant reassessment of the topical regimen and wound care plan.

Question 50Wound assessment, measurement, and documentation

Wound length and width are documented in which unit of measure and format?

  1. Inches, using the smallest gradation on the ruler
  2. Centimeters, recorded as length × width Correct answer.
  3. Millimeters, rounded to the nearest whole number
  4. Square centimeters, recorded as a single value

Explanation

Linear wound dimensions are recorded in centimeters as length (longest dimension) followed by width measured perpendicular to it. Using a consistent metric convention allows any clinician to compare measurements over time. Area in square centimeters is a derived figure and does not replace the individual linear measurements.