CRRN Wound Care and Skin Integrity in Rehabilitation 2 — Questions and Answers
Question 1: A patient has a venous stasis ulcer on the medial gaiter area of the right leg. Which treatment is FUNDAMENTAL to healing this wound type?
- Strict elevation with no ambulation
- Multilayer compression therapy to reduce venous hypertension (Correct answer)
- Arterial revascularization surgery
- Daily wet-to-dry gauze dressing changes
Correct answer: Multilayer compression therapy to reduce venous hypertension
Venous leg ulcers are caused by chronic venous hypertension; multilayer compression therapy (e.g., 30–40 mmHg) is the cornerstone treatment that addresses the underlying pathophysiology.
Question 2: A CRRN documents a deep tissue pressure injury (DTPI) on the heel. Which description BEST matches this classification?
- A blister filled with serous fluid over an area of redness
- A localized area of discolored, intact or non-intact skin due to underlying soft tissue injury from pressure (Correct answer)
- Full-thickness skin loss with exposed bone
- Superficial skin erosion with a pink wound bed
Correct answer: A localized area of discolored, intact or non-intact skin due to underlying soft tissue injury from pressure
DTPI presents as persistent non-blanchable deep red, maroon, or purple discoloration from injury to underlying tissue, which may evolve rapidly even when skin appears intact.
Question 3: A rehabilitation patient has a surgically debrided wound with no signs of infection and no contraindications to healing. Which wound bed characteristic indicates OPTIMAL healing progress?
- Yellow fibrinous tissue covering >50% of the wound bed
- Bright red, moist granulation tissue filling the wound base (Correct answer)
- Pale pink wound edges with no migration
- Dry, dark eschar at the wound center
Correct answer: Bright red, moist granulation tissue filling the wound base
Bright red, moist granulation tissue indicates robust vascular ingrowth and healthy wound healing; yellow fibrin and eschar indicate stalled or complicated healing.
Question 4: A patient with a diabetic foot ulcer has signs of wound infection. Which assessment finding BEST confirms local wound infection?
- Mild redness at wound edges only
- Increased wound pain, warmth, purulent exudate, and periwound erythema > 2 cm (Correct answer)
- Thin serous drainage and no odor
- Granulating tissue at the wound margins
Correct answer: Increased wound pain, warmth, purulent exudate, and periwound erythema > 2 cm
Local wound infection is confirmed by classic signs: increased pain, warmth, purulent exudate, odor, and periwound erythema extending more than 2 cm from the wound edge.
Question 5: A rehabilitation nurse is performing a Braden Scale assessment. Which subscale DIRECTLY assesses the patient's level of physical activity?
- Moisture
- Activity (Correct answer)
- Friction and Shear
- Nutrition
Correct answer: Activity
The Braden Scale 'Activity' subscale directly scores the degree of physical activity, ranging from bedfast (1) to walks frequently (4), indicating mobility-related pressure injury risk.
Question 6: A patient with heel pressure injuries is being positioned in bed. Which position is BEST to protect the heels?
- Elevate heels on a standard pillow with the knees straight
- Float the heels completely off the surface using pillows placed under the calves (Correct answer)
- Apply donut-shaped heel protectors to redistribute pressure
- Keep the patient in Trendelenburg position at all times
Correct answer: Float the heels completely off the surface using pillows placed under the calves
Floating the heels by placing pillows under the calves completely offloads the heel from the mattress surface; donut devices create a pressure ring around the wound.
CRRN Wound Care and Skin Integrity in Rehabilitation 2
A patient has a venous stasis ulcer on the medial gaiter area of the right leg.
Which treatment is FUNDAMENTAL to healing this wound type?