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CWCN practice questions

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Question 1Wound assessment and patient evaluation

When measuring a wound's surface area for serial comparison, which approach gives the most consistent results?

  1. Record only the widest diameter
  2. Estimate area from a photograph
  3. Measure the wound depth only
  4. Measure perpendicular length and width Correct answer.

Explanation

Surface area is best estimated by multiplying the greatest length by the greatest width measured perpendicular to it. Using the same method and patient position each time improves reliability. Depth is recorded separately and does not substitute for surface measurement.

Question 2Wound assessment and patient evaluation

Which Braden subscale assesses the patient's ability to change and control body position?

  1. Mobility Correct answer.
  2. Sensory perception
  3. Friction and shear
  4. Activity

Explanation

The Braden Mobility subscale rates the patient's ability to make major and minor position changes. Activity rates overall bed and chair time, while sensory perception rates responsiveness to pressure-related discomfort. Friction and shear rate forces against the skin during movement.

Question 3Wound assessment and patient evaluation

A pressure injury presents as intact skin with a localized area of nonblanchable erythema. Which stage is this?

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

Explanation

Stage 1 pressure injury is characterized by intact skin with nonblanchable erythema over a bony prominence. Stage 2 involves partial-thickness loss with a shallow open ulcer or intact blister. Deep tissue injury and unstageable injuries have different skin and tissue findings.

Question 4Wound assessment and patient evaluation

Which tissue type in a healing wound bed is described as beefy red and granular?

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

Explanation

Granulation tissue is new connective tissue and capillaries that appear red, moist, and pebbled. Slough is yellow or tan devitalized tissue, and eschar is black or brown necrotic tissue. Fibrin appears as a pale, stringy covering rather than a granular bed.

Question 5Wound assessment and patient evaluation

What is the preferred method for obtaining a culture from a chronic wound suspected of infection?

  1. Obtain tissue by biopsy after cleansing Correct answer.
  2. Swab the wound surface before cleansing
  3. Aspirate fluid through intact skin
  4. Culture the removed dressing

Explanation

Tissue biopsy or curettage after cleansing is preferred because surface swabs can reflect colonizing organisms rather than deep infection. Proper cleansing removes superficial contaminants. Culture results guide antibiotic selection when clinical infection is present.

Question 6Wound assessment and patient evaluation

Serosanguineous wound exudate is best described as:

  1. Clear and viscous
  2. Thick and purulent
  3. Dark brown and malodorous
  4. Pale pink and blood-tinged Correct answer.

Explanation

Serosanguineous exudate is a mixture of serum and blood, giving it a pale pink to blood-tinged appearance. Purulent exudate is thick and opaque, often yellow or green. Dark, malodorous drainage suggests old blood or anaerobic infection.

Question 7Wound assessment and patient evaluation

Maceration of the periwound skin most often results from:

  1. Prolonged moisture exposure Correct answer.
  2. Arterial insufficiency
  3. Topical corticosteroid use
  4. Repeated friction

Explanation

Maceration occurs when skin is overhydrated by prolonged contact with wound exudate, urine, or stool. The skin becomes white, soft, and wrinkled. Friction causes abrasion and arterial disease causes ischemic changes rather than moisture-related softening.

Question 8Wound assessment and patient evaluation

Which approach is most appropriate for assessing pain in a patient with advanced dementia who cannot self-report?

  1. Use a validated behavioral scale Correct answer.
  2. Record zero if no verbal report
  3. Ask family to rate pain
  4. Use the last recorded score

Explanation

Patients with advanced dementia may express pain through facial expression, body language, and vocalization. A validated behavioral pain scale should be used consistently. Assuming absence of pain because the patient cannot report it leads to undertreatment.

Question 9Wound assessment and patient evaluation

An ankle-brachial index of 0.62 in a patient with a lower extremity wound suggests:

  1. Venous hypertension
  2. Arterial insufficiency Correct answer.
  3. Medial arterial calcification
  4. Normal arterial perfusion

Explanation

An ankle-brachial index below 0.90 indicates arterial insufficiency, and values between 0.50 and 0.69 suggest moderate arterial disease. Normal perfusion is generally 1.00 to 1.40. Calcification can falsely elevate the index above 1.40.

Question 10Wound assessment and patient evaluation

Which findings most strongly suggest a venous leg ulcer rather than an arterial ulcer?

  1. Shallow irregular ulcer with edema and hemosiderin staining Correct answer.
  2. Punched-out ulcer with a pale, dry base and minimal exudate
  3. Round ulcer over the lateral malleolus with black eschar
  4. Ulcer on the dorsum of the foot with absent pulses

Explanation

Venous ulcers are typically shallow, irregular, and located in the gaiter area with edema, hemosiderin staining, and moist wound beds. Arterial ulcers are more often punched out, pale, and painful, with diminished pulses. Location and surrounding skin findings help distinguish the two.

Question 11Wound assessment and patient evaluation

Undermining in a wound is measured by:

  1. Measuring the widest surface diameter
  2. Measuring from the wound edge to periwound
  3. Probing under the edge with a swab and measuring Correct answer.
  4. Measuring the deepest point of the wound base

Explanation

Undermining is assessed by gently inserting a moistened cotton-tipped applicator beneath the wound edge and measuring the distance to the limit of the tract. It is recorded by clock position. Surface diameter and depth do not describe undermining.

Question 12Wound assessment and patient evaluation

When tracing a wound to document its size, the nurse should:

  1. Trace in varying positions
  2. Trace the skin-level perimeter consistently Correct answer.
  3. Trace only the widest diameter
  4. Trace the wound base

Explanation

Wound tracing follows the skin-level perimeter with the patient in a consistent position so that serial measurements are comparable. Tracing the base or changing patient position introduces variability. The widest diameter alone does not capture wound shape.

Question 13Wound assessment and patient evaluation

A total Braden score of 11 places a patient in which risk category?

  1. Mild risk
  2. High risk Correct answer.
  3. No risk
  4. Moderate risk

Explanation

Braden scores of 10 to 12 indicate high risk for pressure injury. Scores of 15 to 18 indicate mild risk, 13 to 14 indicate moderate risk, and 19 to 23 indicate no risk. Lower scores reflect greater impairment and higher risk.

Question 14Wound assessment and patient evaluation

Which finding is the most reliable indicator of wound infection?

  1. Progressive wound contraction
  2. Rising pain with purulent drainage Correct answer.
  3. Healthy granulation tissue at the base
  4. Clear serous drainage from the wound

Explanation

Increasing pain and purulent drainage are classic signs of wound infection and should prompt further evaluation. Granulation, serous drainage, and contraction are consistent with normal healing. Systemic signs such as fever may also be present but are not always.

Question 15Wound assessment and patient evaluation

The 10-g monofilament test is used to assess:

  1. Joint mobility
  2. Arterial perfusion
  3. Vibratory sensation
  4. Protective sensation Correct answer.

Explanation

The 10-g monofilament assesses protective sensation by applying a standardized force to specified plantar sites. Loss of protective sensation identifies patients at risk for neuropathic ulcers. Arterial perfusion is assessed by pulses and ankle-brachial index, not monofilament testing.

Question 16Wound assessment and patient evaluation

Moisture-associated skin damage differs from a pressure injury because moisture-associated skin damage:

  1. Is caused by shear over a bony prominence
  2. Follows moisture patterns, not pressure Correct answer.
  3. Always involves full-thickness loss
  4. Requires a Braden score below 9

Explanation

Moisture-associated skin damage results from prolonged contact with moisture and follows the pattern of exposure, such as skin folds or under a dressing. Pressure injury develops from pressure and shear over a bony prominence. The two conditions can coexist and require different prevention strategies.

Question 17Wound assessment and patient evaluation

Which laboratory value is most useful as an indicator of recent nutritional status in a patient with a chronic wound?

  1. Prealbumin Correct answer.
  2. Platelet count
  3. Hemoglobin
  4. Creatinine

Explanation

Prealbumin has a short half-life and responds relatively quickly to changes in protein and energy intake. It is therefore useful for assessing recent nutritional status in wound healing. Hemoglobin, platelets, and creatinine do not primarily reflect recent protein-calorie intake.

Question 18Wound assessment and patient evaluation

Which documentation entry best meets standards for wound assessment?

  1. 2 cm ulcer with 50% slough and moderate drainage Correct answer.
  2. Healing is progressing as expected
  3. The wound appears cleaner and less red today
  4. No significant change from the prior note

Explanation

Objective wound documentation includes measurable size, tissue type, and exudate amount. Terms such as cleaner, improving, or unchanged are subjective and cannot be compared over time. Consistent objective descriptors support continuity of care.

Question 19Wound assessment and patient evaluation

To obtain a reliable serial wound photograph, the nurse should:

  1. Photograph with flash each time
  2. Keep distance, lighting, and scale constant Correct answer.
  3. Photograph before cleansing the wound
  4. Vary the angle for each photograph

Explanation

Serial wound photographs are comparable only when distance, lighting, angle, and a scale reference are kept consistent. Photographing after cleansing follows a standardized routine and reduces distortion. Varying technique makes interval comparison unreliable.

Question 20Wound assessment and patient evaluation

A foul odor from a wound most commonly indicates:

  1. Chronic venous insufficiency
  2. Recent surgical closure of the wound
  3. Normal progress of granulation tissue
  4. Bacterial colonization or infection Correct answer.

Explanation

Foul odor usually reflects bacterial colonization or infection, particularly with anaerobic organisms or heavy bioburden. It is not a normal feature of granulation tissue. Odor should be assessed after cleansing and considered alongside other signs of infection.

Question 21Wound assessment and patient evaluation

Which wound characteristic should prompt consideration of biopsy for suspected malignancy?

  1. Granulation tissue with moderate exudate
  2. Periwound maceration and erythema
  3. Smooth margins with decreasing size
  4. Raised, rolled edges that fail to heal Correct answer.

Explanation

A wound with raised, rolled, or everted edges that does not heal despite appropriate care raises concern for malignancy such as squamous cell carcinoma or basal cell carcinoma. Nonhealing atypical wounds warrant biopsy. Smooth margins and decreasing size suggest normal healing.

Question 22Wound assessment and patient evaluation

A positive probe-to-bone test in a diabetic foot ulcer most strongly suggests:

  1. Biofilm formation
  2. Cellulitis
  3. Osteomyelitis Correct answer.
  4. Arterial insufficiency

Explanation

A probe-to-bone test is performed by gently probing the ulcer base with a sterile instrument; bone contact is highly suggestive of osteomyelitis in a diabetic foot ulcer. It should be interpreted with clinical signs and imaging. Cellulitis, biofilm, and arterial disease do not produce bone contact on probing.

Question 23Wound assessment and patient evaluation

A pressure injury has not decreased in size after 4 weeks of appropriate offloading and local care. What is the most appropriate next step?

  1. Reassess the cause and revise the plan Correct answer.
  2. Stop offloading the wound
  3. Refer immediately for skin grafting
  4. Continue the same plan for 8 more weeks

Explanation

Lack of measurable improvement after 4 weeks of appropriate care signals the need to reassess causative factors, adherence, nutrition, perfusion, infection, and the treatment plan. Continuing an ineffective plan delays healing. Skin grafting is considered only after reversible factors are addressed.

Question 24Wound assessment and patient evaluation

Which finding in a patient with end-stage renal disease suggests calciphylaxis?

  1. Superficial maceration confined to skin folds
  2. Shallow ulcers with surrounding hemosiderin staining
  3. Painless ulcers over prominent bony areas
  4. Painful violaceous plaques with fatty-area necrosis Correct answer.

Explanation

Calciphylaxis presents with painful violaceous plaques and subcutaneous necrosis, typically in fatty areas such as the abdomen, thighs, and breasts in patients with end-stage renal disease. It is distinct from pressure, venous, or moisture-related injury. Early recognition is important because mortality is high.

Question 25Wound assessment and patient evaluation

A chronic wound with a shiny, slimy film that recurs after cleansing most likely has:

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

Explanation

Biofilm is a structured community of microorganisms that adheres to the wound bed and reforms quickly after cleansing. It can appear as a shiny, slimy, or gelatinous film and contributes to chronicity and resistance to treatment. Eschar and granulation tissue have different visual characteristics.

Question 26Wound assessment and patient evaluation

Which pressure injury stage is characterized by intact skin with a localized area of non-blanchable erythema?

  1. Stage 4
  2. Stage 3
  3. Stage 1 Correct answer.
  4. Stage 2

Explanation

Stage 1 pressure injury is defined by intact skin with non-blanchable erythema over a bony prominence. Higher stages involve increasing depth of tissue loss, from partial-thickness dermis loss in Stage 2 to full-thickness loss with exposed deep structures in Stages 3 and 4.

Question 27Wound assessment and patient evaluation

Granulation tissue in a healing wound is best described as:

  1. Black, dry, and leathery
  2. Pale, thin, and shiny
  3. Yellow, stringy, and adherent
  4. Red, moist, and pebbly Correct answer.

Explanation

Granulation tissue is healthy new tissue that appears red, moist, and pebbly because of new capillary loops and collagen. Its presence generally signals active healing rather than necrosis or colonization.

Question 28Wound assessment and patient evaluation

Slough in a wound bed is best described as:

  1. Black, hard, and leathery
  2. Yellow, soft, and stringy Correct answer.
  3. Pink, thin, and epithelial
  4. Red, granular, and moist

Explanation

Slough is devitalized tissue that appears yellow, tan, gray, or green and is soft, moist, and stringy. It can adhere to the wound bed and must be distinguished from hard, dry eschar.

Question 29Wound assessment and patient evaluation

A wound dressing is saturated with exudate within 8 hours of application. How should the exudate amount be documented?

  1. Scant
  2. Minimal
  3. Large Correct answer.
  4. Moderate

Explanation

Exudate amount is often described as none, scant, minimal, moderate, or large based on how quickly the dressing becomes saturated. Saturation within hours indicates a large or copious amount and should prompt reassessment of dressing choice and underlying causes.

Question 30Wound assessment and patient evaluation

Which pain assessment approach is most appropriate for a cognitively intact adult with a painful wound?

  1. PAINAD behavioral scale
  2. Facial grimace assessment only
  3. Numeric 0-to-10 scale Correct answer.
  4. FLACC behavioral scale

Explanation

Cognitively intact adults can self-report pain, so a validated self-report scale such as the 0-to-10 numeric rating scale is preferred. Behavioral scales are used when self-report is unreliable, and a single facial sign is insufficient.

Question 31Wound assessment and patient evaluation

Systemic corticosteroid therapy most commonly affects wound healing by:

  1. Increasing collagen deposition in the wound
  2. Suppressing inflammation and collagen Correct answer.
  3. Accelerating epithelialization across the wound
  4. Improving tensile strength of healed tissue

Explanation

Corticosteroids suppress the inflammatory phase and reduce fibroblast activity and collagen synthesis, which can delay healing and weaken repaired tissue. The effect is dose- and duration-related and should be considered during wound assessment.

Question 32Wound assessment and patient evaluation

Which patient factor most directly impairs wound healing by causing vasoconstriction and tissue hypoxia?

  1. Cigarette smoking Correct answer.
  2. Male sex
  3. Severe obesity
  4. Advanced age over 80 years

Explanation

Nicotine causes vasoconstriction and carbon monoxide reduces oxygen delivery, producing tissue hypoxia that impairs healing. Obesity, age, and sex may influence risk, but smoking has a direct and modifiable hypoxic effect.

Question 33Wound assessment and patient evaluation

Isotonic normal saline is preferred for routine wound cleansing mainly because it:

  1. Does not damage healthy tissue Correct answer.
  2. Dissolves necrotic tissue chemically
  3. Kills bacteria on contact
  4. Stimulates granulation tissue

Explanation

Normal saline is isotonic and non-cytotoxic, so it removes debris without injuring newly formed tissue. Antiseptics may be indicated in specific situations but can be cytotoxic to healing cells when used routinely.

Question 34Wound assessment and patient evaluation

The PUSH tool scores a pressure injury using which three parameters?

  1. Length x width, exudate, tissue type Correct answer.
  2. Braden score, age, and mobility level
  3. Pain score, odor, and periwound color
  4. Depth, undermining, and tunneling distance

Explanation

The PUSH tool combines surface area (length x width), exudate amount, and tissue type into a numerical score. Serial scores are used to track healing or deterioration over time.

Question 35Wound assessment and patient evaluation

The moisture subscale of the Braden Scale assesses:

  1. Urinary or fecal continence alone
  2. Skin exposure to moisture Correct answer.
  3. Frequency of bathing and linen changes
  4. Serum albumin and prealbumin levels

Explanation

The Braden moisture subscale rates how often the skin is exposed to moisture, regardless of the source. It is one of six subscales that together estimate pressure injury risk.

Question 36Wound assessment and patient evaluation

When obtaining a wound culture by the Levine technique, the nurse should:

  1. Swab the wound edge and surrounding intact skin
  2. Irrigate with an antiseptic solution before swabbing
  3. Collect pooled exudate directly from the dressing
  4. Swab a 1-cm2 area of viable wound bed Correct answer.

Explanation

The Levine technique samples viable wound bed tissue by rotating a swab over approximately 1 cm2 with enough pressure to express fluid from deeper tissue. This better reflects the pathogens causing infection than swabbing edges or old exudate.

Question 37Wound assessment and patient evaluation

An ankle-brachial index greater than 1.3 in a patient with a leg wound most likely indicates:

  1. Severe arterial insufficiency
  2. Non-compressible arteries Correct answer.
  3. Moderate arterial insufficiency
  4. Normal arterial perfusion pressure

Explanation

An ABI above 1.3 suggests arteries that do not compress normally, often because of medial calcification in diabetes or renal disease. In that setting the ABI may falsely elevate and other vascular tests are needed.

Question 38Wound assessment and patient evaluation

A 128-Hz tuning fork is used during wound assessment to evaluate:

  1. Vibration perception Correct answer.
  2. Ankle reflex
  3. Protective pressure sensation
  4. Sharp-dull discrimination

Explanation

A 128-Hz tuning fork assesses vibration perception, a large-fiber sensory function often lost in diabetic peripheral neuropathy. Sharp-dull discrimination and protective pressure sensation are tested with other tools.

Question 39Wound assessment and patient evaluation

A chronic wound with rolled, thickened wound edges most likely indicates:

  1. Normal granulation tissue formation
  2. Rapid epithelialization of the wound
  3. Acute surgical wound dehiscence
  4. Chronicity and stalled healing Correct answer.

Explanation

Rolled or thickened edges suggest prolonged inflammation and failed migration of epithelial cells, often seen in chronic wounds. They signal that the wound is not progressing normally and may need reassessment or intervention.

Question 40Wound assessment and patient evaluation

Green-blue wound exudate with a sweet or grapelike odor most suggests infection by:

  1. Streptococcus pyogenes
  2. Pseudomonas aeruginosa Correct answer.
  3. Staphylococcus aureus
  4. Candida albicans

Explanation

Pseudomonas aeruginosa can produce green-blue pigment and a characteristic sweet or grapelike odor. Culture remains necessary because color and odor are suggestive rather than diagnostic.

Question 41Wound assessment and patient evaluation

The REEDA tool is used to assess which aspect of a surgical wound?

  1. Redness, edema, ecchymosis, drainage, approximation Correct answer.
  2. Pressure injury stage, depth, and undermining
  3. Nutritional status, weight trend, and albumin
  4. Arterial perfusion and ankle-brachial index measurements

Explanation

REEDA stands for redness, edema, ecchymosis, discharge, and approximation of wound edges. It provides a structured way to evaluate surgical wound healing and detect early complications.

Question 42Wound assessment and patient evaluation

Using the ISTAP skin tear classification, a Type 1 skin tear is one in which:

  1. Complete loss of the skin flap
  2. Partial loss of the skin flap with viable tissue
  3. No skin loss; flap repositionable Correct answer.
  4. Involvement of tendon, muscle, or bone

Explanation

ISTAP Type 1 describes a skin tear with no skin loss and a flap that can be repositioned to cover the wound. Type 2 involves partial flap loss, and Type 3 involves complete flap loss.

Question 43Wound assessment and patient evaluation

Which unintentional weight loss finding best supports a diagnosis of malnutrition in an adult?

  1. 2% loss in 1 month
  2. 5% loss in 1 month Correct answer.
  3. 1% loss in 2 weeks
  4. 3% loss in 6 months

Explanation

Unintentional loss of more than 5% of body weight in 1 month, or more than 10% in 6 months, is a recognized indicator of malnutrition risk. Smaller or slower losses may still matter but do not meet that threshold.

Question 44Wound assessment and patient evaluation

For a patient with predictable severe pain at dressing changes, the nurse should:

  1. Give prescribed analgesic 30-60 minutes before Correct answer.
  2. Give analgesic immediately before the procedure
  3. Use ice instead of prescribed medication
  4. Avoid analgesia so true pain can be assessed

Explanation

Analgesia should be timed to peak at the start of the dressing change, commonly 30 to 60 minutes beforehand depending on the drug. Untreated predictable pain can increase anxiety and make future care more difficult.

Question 45Wound assessment and patient evaluation

A deep tissue pressure injury is best identified by:

  1. Intact skin with non-blanchable redness only
  2. Full-thickness loss with visible bone or tendon
  3. Superficial shiny blister over a bony prominence
  4. Persistent deep maroon or purple discoloration Correct answer.

Explanation

Deep tissue pressure injury presents as intact or non-intact skin with persistent deep red, maroon, or purple discoloration that may evolve over hours to days. It reflects damage to deeper tissue and is not the same as Stage 1 erythema.

Question 46Wound assessment and patient evaluation

A transcutaneous oxygen pressure (TcPO2) reading of 20 mm Hg near a lower extremity wound most strongly suggests:

  1. Adequate perfusion for wound healing
  2. Isolated venous insufficiency
  3. Normal arterial flow
  4. Poor healing from tissue hypoxia Correct answer.

Explanation

TcPO2 values below about 30 mm Hg indicate reduced oxygen delivery to the skin and poor potential for wound healing. Values in the 30 to 40 mm Hg range are borderline, while higher values suggest better perfusion.

Question 47Wound assessment and patient evaluation

Which test is most specific for diagnosing osteomyelitis in a diabetic foot ulcer?

  1. Plain radiograph of the foot
  2. Bone biopsy with culture Correct answer.
  3. Erythrocyte sedimentation rate
  4. Superficial wound swab culture

Explanation

Bone biopsy with histology and culture is the most specific test for osteomyelitis because it identifies organisms and confirms bone involvement. Imaging and inflammatory markers can support the diagnosis but are less specific.

Question 48Wound assessment and patient evaluation

Which method provides the most accurate measurement of wound surface area?

  1. Photograph without scale
  2. Ruler length only
  3. Visual estimate
  4. Computerized planimetry Correct answer.

Explanation

Computerized planimetry traces the wound perimeter digitally and calculates area with greater accuracy than linear or visual methods. Accurate photography requires a scale reference and consistent technique.

Question 49Wound assessment and patient evaluation

Which finding best distinguishes critical colonization from a spreading wound infection?

  1. Spreading erythema well beyond the wound edge
  2. Local delayed healing without systemic signs Correct answer.
  3. Purulent drainage with surrounding induration
  4. Fever, hypotension, and altered mental status

Explanation

Critical colonization is a state of increased bioburden that impairs healing locally without the spreading erythema, induration, or systemic signs of true infection. True infection typically produces spreading inflammation or systemic illness.

Question 50Wound assessment and patient evaluation

For a patient with a malignant wound receiving palliative care, the primary wound assessment goal should be to:

  1. Obtain weekly tissue biopsy for pathology
  2. Control odor, bleeding, and pain for comfort Correct answer.
  3. Achieve complete wound closure with debridement
  4. Measure wound area daily and photograph changes

Explanation

In palliative care, wound assessment focuses on symptoms and quality of life rather than closure. Priorities include controlling odor, bleeding, pain, exudate, and infection while minimizing distressing interventions.