Wound Care Certification Wound Assessment and Staging Questions and Answers

Question 1

A clinician is assessing a pressure injury on a patient's sacrum.
The wound bed is completely obscured by a thick, leathery, black eschar.
What is the correct stage for this pressure injury according to the NPIAP guidelines?

Accepted Answer

Unstageable

Answer

Stage 3

Answer

Stage 4

Answer

Deep Tissue Injury

Question 2

During a skin assessment, a nurse notes an area on the patient's heel that is intact, with a localized area of persistent, non-blanchable deep red discoloration. The patient reports pain in the area, which feels boggy upon palpation compared to the surrounding tissue. Which of the following is the most likely classification for this finding?

Accepted Answer

Deep Tissue Pressure Injury

Answer

Stage 1 Pressure Injury

Answer

Stage 2 Pressure Injury

Answer

Venous Stasis Ulcer

Question 3

A wound care nurse is assessing a shallow, open ulcer on a patient's ischium. The wound bed is pink and moist, with partial-thickness loss of the dermis. There is no slough, eschar, or granulation tissue visible. Adipose tissue is not exposed. How should this pressure injury be staged?

Accepted Answer

Stage 2

Answer

Stage 1

Answer

Stage 3

Answer

Unstageable

Question 4

Which of the following findings would correctly identify a pressure injury as Stage 3?

Accepted Answer

Full-thickness skin loss with visible adipose (fat) tissue and granulation tissue.

Answer

Intact skin with non-blanchable erythema.

Answer

Partial-thickness skin loss with exposed dermis.

Answer

Full-thickness skin and tissue loss with exposed muscle and bone.

Question 5

A patient presents with a pressure injury over the coccyx. The assessment reveals full-thickness skin and tissue loss, with directly palpable fascia and muscle in the wound bed. Slough is present in 25% of the wound base, and undermining is noted from the 2 o'clock to 5 o'clock position. This wound would be classified as:

Accepted Answer

Stage 4

Answer

Stage 2

Answer

Stage 3

Answer

Unstageable

Question 6

A comprehensive wound assessment should include multiple components to guide the plan of care. Which of the following is the MOST complete list of essential assessment components?

Accepted Answer

Anatomical location, dimensions (length, width, depth), wound bed tissue types, drainage characteristics, and condition of the periwound skin.

Answer

Wound size and color only.

Answer

Location, size, drainage amount, and pain level.

Answer

Presence of odor and the patient's nutritional status.