NMC OSCE Wound Care & Tissue Viability 1 — Questions and Answers
Question 1: 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?
- Category 1 (Correct answer)
- Category 2
- Category 3
- Category 4
Correct 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.
Question 2: 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?
- Hydrocolloid dressing
- Alginate dressing (Correct answer)
- Hydrogel dressing
- Transparent film dressing
Correct 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.
Question 3: During a wound assessment, the nurse documents 'undermining' present at the wound edge. What does this term correctly describe?
- Ragged, irregular wound edges caused by trauma
- Tissue destruction extending beneath intact skin at the wound margin (Correct answer)
- Inward rolling of wound edges preventing epithelialisation
- New granulation tissue growing upward from the wound base
Correct 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.
Question 4: The TIME framework is used in wound bed preparation. What does the 'M' in TIME stand for?
- Measurement of wound dimensions
- Moisture balance (Correct answer)
- Microorganism control
- Margin assessment
Correct 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.
Question 5: A patient has a Waterlow score of 17 following assessment. Which risk category does this score indicate?
- At risk (score 10–14)
- High risk (score 15–19) (Correct answer)
- Very high risk (score 20+)
- No risk (score below 10)
Correct 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.
Question 6: A nurse observes yellow/white soft fibrinous material covering the wound bed during assessment. This material is correctly identified as:
- Healthy granulation tissue
- Slough (Correct answer)
- Eschar
- Epithelial tissue
Correct 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.
Question 7: What is the recommended wound irrigation pressure range to effectively cleanse a wound without causing trauma to the wound bed?
- 1–4 psi
- 4–15 psi (Correct answer)
- 15–25 psi
- 25–35 psi
Correct 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.
NMC OSCE Wound Care & Tissue Viability 1
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?