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 nurse assesses a patient with intact skin showing non-blanchable erythema over the sacrum. According to the EPUAP classification, which pressure ulcer category does this represent?
Answer: Category 1
Category 1 pressure ulcers involve intact skin with non-blanchable erythema, typically over a bony prominence, and represent the earliest stage in the EPUAP classification.
A patient has a heavily exuding wound on their lower leg. Which dressing type is MOST appropriate to manage high levels of exudate while maintaining a moist wound environment?
Answer: Alginate dressing
Alginate dressings are highly absorbent and convert to a gel on contact with wound exudate, making them ideal for heavily exuding wounds while maintaining moisture balance.
During a wound assessment, the nurse documents 'undermining' present at the wound edge. What does this term correctly describe?
Answer: Tissue destruction extending beneath intact skin at the wound margin
Undermining describes tissue destruction that extends beneath intact skin surrounding the wound, creating a pocket or channel that is not visible at the surface.
The TIME framework is used in wound bed preparation. What does the 'M' in TIME stand for?
Answer: Moisture balance
In the TIME framework, 'M' represents Moisture balance, addressing the management of wound exudate to prevent both maceration and desiccation of wound tissue.
A patient has a Waterlow score of 17 following assessment. Which risk category does this score indicate?
Answer: High risk (score 15–19)
A Waterlow score of 15–19 places a patient in the 'high risk' category for pressure ulcer development, requiring preventive interventions.
A nurse observes yellow/white soft fibrinous material covering the wound bed during assessment. This material is correctly identified as:
Answer: Slough
Slough is devitalised fibrinous tissue appearing yellow or white and soft in consistency, which must be removed through debridement to allow wound healing to progress.
What is the recommended wound irrigation pressure range to effectively cleanse a wound without causing trauma to the wound bed?
Answer: 4–15 psi
An irrigation pressure of 4–15 psi effectively removes debris and bacteria from the wound bed without causing mechanical trauma to healing tissue.