CPNRE Wound Care and Skin Integrity

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?

Accepted Answer

Stage II

Answer

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?

Accepted Answer

Hydrocolloid dressing to maintain a moist wound environment

Answer

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?

Accepted Answer

Purulent drainage with increased warmth and periwound erythema

Answer

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?

Accepted Answer

Use a 35 mL syringe with a 19-gauge angiocatheter and normal saline

Answer

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?

Accepted Answer

The wound is left open and heals from the base up through granulation, contraction, and epithelialization

Answer

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.

CPNRE - Canadian Practical Nurse Registration Examination Practice Test

CPNRE - Canadian Practical Nurse Registration Examination Practice Test

CPNRE Wound Care and Skin Integrity