NCWO Wound Assessment 2

Question 1

A Stage 3 pressure injury is defined as:

Accepted Answer

Full-thickness skin loss without exposed fascia, bone, tendon, or muscle

Answer

Non-blanchable erythema of intact skin

Answer

Partial-thickness loss of skin with exposed dermis

Answer

Full-thickness skin and tissue loss with exposed or palpable fascia, bone, or muscle

Question 2

The Braden Scale assesses pressure injury risk using which subscales?

Accepted Answer

Sensory perception, moisture, activity, mobility, nutrition, friction/shear

Answer

Age, BMI, diagnosis, mobility, continence, skin condition

Answer

Wound size, depth, exudate, tissue type, periwound skin

Answer

Pain, edema, temperature, color, pulses

Question 3

An unstageable pressure injury is characterized by:

Accepted Answer

Full-thickness tissue loss covered by slough or eschar obscuring depth

Answer

Non-blanchable erythema over a bony prominence

Answer

Suspected deep tissue injury with intact skin

Answer

Partial-thickness loss limited to the epidermis

Question 4

Which wound assessment tool uses the acronym TIME to guide debridement decisions?

Accepted Answer

Tissue, Infection/Inflammation, Moisture, Edge

Answer

Temperature, Infection, Measurement, Exudate

Answer

Tissue, Ischemia, Maceration, Edema

Answer

Tunneling, Infection, Moisture, Erosion

Question 5

A deep tissue pressure injury (DTPI) typically presents as:

Accepted Answer

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration

Answer

Open wound with yellow slough in the base

Answer

Shallow open wound with a pink or red wound bed

Answer

Full-thickness tissue loss with exposed bone

Question 6

Which exudate characteristic raises the strongest concern for wound infection?

Accepted Answer

Purulent, thick, malodorous exudate

Answer

Serous, thin, and clear exudate

Answer

Serosanguineous exudate in moderate amounts

Answer

Sanguineous exudate immediately post-debridement