NCWO Wound Assessment 3

Question 1

The ankle-brachial index (ABI) value that indicates significant arterial insufficiency and requires referral is:

Accepted Answer

Less than 0.5

Answer

0.9–1.2

Answer

0.7–0.89

Answer

0.5–0.69

Question 2

Which of the following is the most reliable method to confirm biofilm presence in a chronic wound?

Accepted Answer

Wound biopsy and microscopy

Answer

Wound culture swab

Answer

Visual inspection for slough

Answer

Elevated serum white blood cell count

Question 3

Wound edge epibole (rolled or thickened edges) indicates:

Accepted Answer

Inward rolling of the epidermis impeding wound closure

Answer

Active migration of epithelial cells across the wound

Answer

Excessive wound contraction causing scar formation

Answer

Periwound infection spreading under intact skin

Question 4

When measuring wound depth, the WOC nurse should use a:

Accepted Answer

Sterile cotton-tipped applicator inserted perpendicular to the wound bed

Answer

Transparent ruler placed over the wound

Answer

Measuring tape along the wound margin

Answer

Disposable probe inserted at a 45-degree angle

Question 5

Venous leg ulcers (VLUs) are most commonly located:

Accepted Answer

In the gaiter zone (medial lower leg above the medial malleolus)

Answer

On the plantar surface of the foot

Answer

Over the lateral malleolus

Answer

On the dorsum of the foot

Question 6

A wound swab culture is most appropriately collected using the:

Accepted Answer

Levine technique (rotating swab under pressure over 1 cm² of clean tissue)

Answer

Z-stroke across all wound surfaces including slough

Answer

Swab of wound exudate directly from the dressing

Answer

Swab of the periwound skin margin