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
The ankle-brachial index (ABI) value that indicates significant arterial insufficiency and requires referral is:
Answer: Less than 0.5
An ABI below 0.5 indicates severe arterial insufficiency and warrants urgent vascular surgery referral before applying compression therapy.
Which of the following is the most reliable method to confirm biofilm presence in a chronic wound?
Answer: Wound biopsy and microscopy
Biofilm can only be definitively confirmed through wound biopsy and microscopic analysis, as it is not reliably detected by swab culture or visual inspection alone.
Wound edge epibole (rolled or thickened edges) indicates:
Answer: Inward rolling of the epidermis impeding wound closure
Epibole occurs when the epidermis rolls inward and downward at the wound edge, preventing epithelial cells from migrating across the wound bed.
When measuring wound depth, the WOC nurse should use a:
Answer: Sterile cotton-tipped applicator inserted perpendicular to the wound bed
A sterile cotton-tipped applicator inserted perpendicular to the wound bed and measured against a ruler is the standard bedside technique for wound depth measurement.
Venous leg ulcers (VLUs) are most commonly located:
Answer: In the gaiter zone (medial lower leg above the medial malleolus)
VLUs characteristically occur in the gaiter zone of the medial lower leg, from the ankle to mid-calf, due to sustained venous hypertension in that region.
A wound swab culture is most appropriately collected using the:
Answer: Levine technique (rotating swab under pressure over 1 cm² of clean tissue)
The Levine technique—rotating the swab under sufficient pressure over a 1 cm² area of clean wound tissue—provides the most representative bacterial sample.