Wound Assessment Flashcards
6 cards from real NCWO practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Wound Assessment flashcards as text
A Stage 3 pressure injury is defined as:
Answer: Full-thickness skin loss without exposed fascia, bone, tendon, or muscle
A Stage 3 pressure injury involves full-thickness skin loss where subcutaneous fat may be visible but fascia, bone, tendon, and muscle are not exposed.
The Braden Scale assesses pressure injury risk using which subscales?
Answer: Sensory perception, moisture, activity, mobility, nutrition, friction/shear
The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear, with lower scores indicating higher risk.
An unstageable pressure injury is characterized by:
Answer: Full-thickness tissue loss covered by slough or eschar obscuring depth
An unstageable pressure injury cannot be staged because the wound bed is obscured by slough or non-removable eschar, preventing depth assessment.
Which wound assessment tool uses the acronym TIME to guide debridement decisions?
Answer: Tissue, Infection/Inflammation, Moisture, Edge
The TIME framework stands for Tissue (non-viable), Infection/Inflammation, Moisture imbalance, and Edge (non-advancing), guiding wound bed preparation.
A deep tissue pressure injury (DTPI) typically presents as:
Answer: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration
DTPI appears as persistent non-blanchable discoloration (deep red, maroon, or purple) with intact or non-intact skin resulting from pressure or shear at the tissue-bone interface.
Which exudate characteristic raises the strongest concern for wound infection?
Answer: Purulent, thick, malodorous exudate
Purulent, thick, and malodorous exudate is a classic clinical indicator of wound infection requiring further assessment and possible intervention.