CPNRE Wound Care and Skin Integrity — Questions and Answers
Question 1: A PN is assessing a client's sacral wound and observes a shallow open ulcer with a red-pink wound bed and no slough. How should this wound be staged?
- Stage I
- Stage II (Correct answer)
- Stage III
- Stage IV
Correct answer: Stage II
A Stage II pressure injury presents as a shallow open ulcer with a pink or red wound bed. There is partial-thickness loss of skin with no slough or eschar. Stage I involves intact skin with non-blanchable erythema; Stage III involves full-thickness tissue loss.
Question 2: A client has a Stage III pressure injury on the heel. The wound bed contains 60% yellow slough and 40% granulation tissue. Which type of dressing would best support debridement?
- Dry gauze dressing changed twice daily
- Hydrocolloid dressing to maintain a moist wound environment (Correct answer)
- Non-adherent silicone dressing
- Dry transparent film dressing
Correct answer: Hydrocolloid dressing to maintain a moist wound environment
Hydrocolloid dressings maintain a moist wound environment that facilitates autolytic debridement, helping to break down slough. A dry gauze dressing would desiccate the wound and impair healing. Moist wound healing is the standard of care.
Question 3: When assessing a client's wound for signs of infection, which finding is most indicative of a wound infection?
- Serosanguineous drainage on day 2 post-surgery
- Mild periwound erythema within 2 cm of the incision on day 1
- Purulent drainage with increased warmth and periwound erythema (Correct answer)
- Slight wound edge approximation separation on day 3
Correct answer: Purulent drainage with increased warmth and periwound erythema
Classic signs of wound infection include purulent (pus-containing) drainage, increased warmth, erythema extending beyond the immediate wound edge, swelling, and pain. Serosanguineous drainage and minimal erythema in the first 24–48 hours are normal inflammatory responses.
Question 4: A PN is performing a wound irrigation. Which of the following techniques is correct?
- Irrigate with hydrogen peroxide to disinfect the wound bed
- Use a 35 mL syringe with a 19-gauge angiocatheter and normal saline (Correct answer)
- Use dry swabs to remove debris before irrigating
- Apply iodine solution to promote granulation tissue growth
Correct answer: Use a 35 mL syringe with a 19-gauge angiocatheter and normal saline
Wound irrigation with a 35 mL syringe and 19-gauge angiocatheter delivers normal saline at the correct pressure (4–15 psi) to remove debris without damaging new tissue. Hydrogen peroxide and iodine are cytotoxic to granulation tissue and should be avoided.
Question 5: Which of the following best describes healing by secondary intention?
- Wound edges are approximated with sutures and the wound heals in a straight line
- A skin graft is placed over the wound to accelerate closure
- The wound is left open and heals from the base up through granulation, contraction, and epithelialization (Correct answer)
- Wound edges are brought together with adhesive strips within 24 hours of injury
Correct answer: The wound is left open and heals from the base up through granulation, contraction, and epithelialization
Secondary intention healing occurs when wound edges cannot be approximated (e.g., infected wounds, pressure injuries). The wound heals from the base upward by granulation tissue formation, wound contraction, and epithelialization. This process is slower and leaves more scarring than primary intention.
Question 6: A client is at high risk for pressure injuries. Which nursing intervention is most effective in preventing skin breakdown?
- Massaging bony prominences vigorously to improve circulation
- Repositioning the client every 2 hours and using a pressure-redistribution surface (Correct answer)
- Applying powder to skin folds to keep them dry
- Using a donut-shaped foam cushion under the coccyx
Correct answer: Repositioning the client every 2 hours and using a pressure-redistribution surface
Regular repositioning (every 2 hours) relieves prolonged pressure on vulnerable tissue, and pressure-redistribution surfaces (e.g., foam or air mattresses) reduce peak interface pressure. Vigorous massage over bony prominences can damage fragile capillaries. Donut cushions concentrate pressure at the edges and are contraindicated.
CPNRE Wound Care and Skin Integrity
A PN is assessing a client's sacral wound and observes a shallow open ulcer with a red-pink wound bed and no slough.
How should this wound be staged?