Wound Care & Tissue Viability Flashcards
7 cards from real NMC OSCE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Wound Care & Tissue Viability flashcards as text
A pressure ulcer shows full thickness skin and tissue loss with exposed bone, tendon, and muscle visible in the wound base. According to the EPUAP classification, what category is this?
Answer: Category 4
Category 4 is the most severe EPUAP classification, describing full thickness tissue loss with exposed or directly palpable bone, tendon, or muscle.
What is the standard clinical method for documenting wound dimensions at the bedside?
Answer: Measure length x width x depth in centimetres using a sterile probe
Standard wound measurement records length (head-to-toe axis), width (side-to-side), and depth in centimetres using a sterile probe or cotton-tipped applicator for accurate documentation.
What is the PRIMARY benefit of maintaining a moist wound environment during the healing process?
Answer: It promotes cell migration and prevents tissue dehydration
A moist wound environment promotes cellular migration, supports the activity of growth factors, and prevents tissue dehydration, all of which accelerate wound healing.
Which type of wound dressing is CONTRAINDICATED in a clinically infected wound?
Answer: Occlusive hydrocolloid dressings
Occlusive hydrocolloid dressings create a sealed anaerobic environment that traps bacteria, potentially worsening clinical infection and are therefore contraindicated in infected wounds.
A patient has a Category 3 pressure ulcer over the sacrum. What is the MOST important nursing intervention to prevent further deterioration?
Answer: Implementing a regular repositioning schedule at least every 2 hours
Regular repositioning at least every 2 hours is the most critical intervention to relieve sustained pressure from the sacrum and prevent further tissue damage and progression.
Which wound characteristic indicates that a wound is healing appropriately and progressing as expected?
Answer: Reduction in wound size with pink/red granulation tissue developing
Reducing wound size alongside the development of pink/red granulation tissue are positive indicators of healthy wound healing and successful tissue repair.
A nurse is preparing to perform a wound dressing change. What should be the FIRST action taken before beginning the procedure?
Answer: Explain the procedure to the patient and obtain their consent
Obtaining informed consent by explaining the procedure to the patient is the first priority before any clinical intervention, upholding the patient's autonomy, dignity, and rights.