Wound Care

What is the recommended timeframe for use of a topical antimicrobial agent initially? 14 days 21 days 3 days 7 days

14 days

An open bottle of normal saline should be discarded after: 12 hours 24 hours 36 hours 48 hours

24 hours

How long after mechanical disruption of a biofilm are antimicrobial treatments most effective? 24 hours 48 hours 72 hours 96 hours

24 hours

At what percent of lean body mass (LBM) loss will restoration of LBM take priority for protein intake over wound healing? 10% 20% 30% 5%

30%

What level of compression is considered therapeutic? 15-25 mmHg 23-30 mmHg 30-42 mmHg 8-15 mmHg

30-42 mmHg

How long does it take for the temperature of the wound base to return to normal after a dressing change? 1 hour 2 hours 3 hours 4 hours

4 hours

What is the pH range of the skin's acid mantle? 3-5.8 4-6.8 5.5-7.2 6.8-8.2

4-6.8

How many layers does the epidermis contain? 2 3 4 5

5

A reasonable A1C goal for most non-pregnant adults with diabetes is: 5% 6% 7% 8%

7%

What is the maximum tensile strength of scar tissue? 100% 20% 50% 80%

80%

What is fibrinolysis? A process that prevents clot extension and dissolves the fibrin clot The activation and aggregation of platelets to form a clot The secretion of growth factors and cytokines from macrophages The stimulation of angiogenesis for new vessel formation

A process that prevents clot extension and dissolves the fibrin clot

What is the term used to describe a pocket of pus under the skin surrounded by inflamed tissue? Abscess Blister Carbuncle Furuncle

Abscess

What is a standard of care? Actions a clinician takes aimed at achieving specific healthcare goals for a patient Actions a practitioner takes to evaluate studies and other sources of evidence for care Actions any reasonable and prudent practitioner would take under similar circumstances Actions that an organization takes to standardize daily operational activities

Actions any reasonable and prudent practitioner would take under similar circumstances

What is one of the reasons to alleviate pain in our wound care patients? Acute pain decreases circulating epinephrine which leads to vasodilation. Acute pain increases circulating epinephrine which leads to vasoconstriction. Pain causes vasodilation which leads to enhanced oxygenation of the tissues. Pain results in increased perfusion of blood to the skin and tissues.

Acute pain increases circulating epinephrine which leads to vasoconstriction.

How does moist wound healing promote re-epithelialization? Allows for cell migration across the wound Increases the number of epithelial cells present in the wound Promotes the formation of granulation tissue Reorganizes collagen fibers in the extracellular matrix

Allows for cell migration across the wound

What type of support surface is classified as an active support surface? Alternating pressure mattress Foam mattress Gel-filled overlay Low air loss overlay

Alternating pressure mattress

What is crepitus? An accumulation of air or gas in the tissues An accumulation of edema in the tissues An accumulation of exudate in the tissues An accumulation of microorganisms in the tissues

An accumulation of air or gas in the tissues

A patient has circular, fluid-filled lesions greater than 1 cm in diameter. What term would you use to describe these lesions? Bulla Macule Papule Vesicle

Bulla

What topical antimicrobial product have studies indicated is capable of penetrating the matrix of a biofilm and penetrating below the surface to affect the underlying bacteria? Cadexomer iodine dressings Gentian violet and methylene blue dressings Iodine impregnated foams Silver dressings

Cadexomer iodine dressings

Which treatments are indicated for shingles? Antiseptic cleanser, antibiotics, and cortisone Calamine lotion, oatmeal bath, and anti-viral medications Pain medications, negative pressure wound therapy, and hot compresses Warm compresses, e-stim, and anti-pyretic medications

Calamine lotion, oatmeal bath, and anti-viral medications

What phrase is used to describe the sequence of events set in motion when tissue is injured? Cascade of healing Cellular arc of healing Cellular cascade Cellular response cycle

Cascade of healing

What type of treatment would be MOST appropriate for controlling odor for a patient receiving palliative care? Calcium alginate dressings Charcoal dressings Crushed metronidazole Hydrocolloid dressings

Charcoal dressings

It is important to consider your patient's religious and cultural beliefs when choosing what type of topical treatment? Collagen dressings Contact layers Hydrocolloid dressings Hydrogel dressings

Collagen dressings

Which dressing would be MOST appropriate when you need to protect a fragile wound base from trauma? Contact layer Gauze dressing Hydrocolloid dressing Transparent film dressing

Contact layer

Initial treatment for pyoderma gangrenosum (PG) involves: Antibiotics Anti-viral medications Bisphosphonates Corticosteroids

Corticosteroids

During a wound assessment, you noticed the wound edges are flush with the wound bed with a clear differentiation of where the wound starts and ends. How would you describe the wound edges? Defined and attached Defined and unattached Undefined and attached Undefined and unattached

Defined and attached

All of the following are purposes of the comprehensive wound assessment EXCEPT: Demonstrate the skills of the wound expert. Determine the cause of the wound. Form the foundation of the care plan. Track progress or deterioration of the wound.

Demonstrate the skills of the wound expert.

Bleeding in a wound indicates tissue trauma goes down to at least which layer? Dermis Epidermis Hypodermis Subcutaneous

Dermis

What is your FIRST course of action if a provider orders an inappropriate wound treatment? Apply the treatment as ordered but note your disagreement in the medical record. Change the treatment order to a more appropriate order and document your rationale. Discuss your concern with the provider and give the rationale for your opinion. Report the inappropriate order to the appropriate supervisor or medical board.

Discuss your concern with the provider and give the rationale for your opinion.

What type of cell grows and creates capillary sprouts? Angiocytes Endothelial Epithelial Platelets

Endothelial

Pain that results from dressing changes would be classified as: Chronic pain Continuous pain Episodic pain Incidental pain

Episodic pain

What is a cause of wound hypoxia? An increase in O2 saturation of hemoglobin Eschar on the wound bed Increase in systemic blood volume Minimal amount of surface exudate

Eschar on the wound bed

How often should wound care competency for staff occur, at a minimum? Every 2 years Every 3 months Every 6 months Every year

Every year

What is the etiology of calciphylaxis? Abnormal accumulation of glucose in the blood Calcification of the blood vessels in end-stage cardiac disease End-stage liver disease with atherosclerosis Excessive calcium deposits in the microvascular system

Excessive calcium deposits in the microvascular system

Which of the following could be a sign of a spreading infection? Epithelial bridging Extending induration Friable granulation tissue Increased wound odor

Extending induration

What cells are responsible for creating the new extracellular matrix and collagen structures during the proliferative phase of wound healing? Endothelial Fibroblasts Macrophages Platelets

Fibroblasts

What characteristic of a healing incision should be evident between post op days 5 and 9? Dehiscence Healing ridge Purulent discharge Warmth

Healing ridge

What does the presence of red tissues in a wound bed signify? Active bleeding Healthy tissue Presence of RBCs Trauma

Healthy tissue

In what sequence do the phases of wound healing normally progress? Hemostasis, inflammatory, maturation, proliferative Hemostasis, inflammatory, proliferative, maturation Inflammatory, hemostasis, maturation, proliferative Proliferative, hemostasis, inflammatory, maturation

Hemostasis, inflammatory, proliferative, maturation

A patient presents with painful small blisters that form along the affected dermatome on either the left or right side of the body with crusts that fall off in 2-3 weeks. What is the most likely etiology of these wound symptoms? Herpes zoster Kaposi sarcoma Pemphigus Sickle cell ulcerations

Herpes zoster

Which of the following is a covert (subtle) sign of a local infection? Erythema Hypergranulation tissue Local warmth Purulent discharge

Hypergranulation tissue

The use of an interprofessional wound team has been shown to: Improve clinical outcomes Improve reimbursement Reduce efficiency in care Result in higher costs

Improve clinical outcomes

Your patient with urinary incontinence presents with a superficial wound on the fatty tissue of the left buttock with diffuse and irregular edges. What type of wound does this MOST likely represent? Candidiasis Incontinence-associated dermatitis (IAD) Intertriginous dermatitis (ITD) Pressure injury

Incontinence-associated dermatitis (IAD)

The primary cells found in the epidermis are the: Keratinocytes Langerhans cells Melanocytes Merkel cells

Keratinocytes

What area of the body does pyoderma gangrenosum usually affect? Arms Face Legs Torso

Legs

What is the most common method for wound measurement? Clock method Linear Photography Tracing

Linear

The presence of microbes located deeper in wound tissues that are multiplying at a rate that causes a host response indicates the presence of: Colonization Contamination Local infection Spreading infection

Local infection

Which skin cell provides protection from harmful UV radiation? Desmosome Keratinocyte Langerhans Melanocyte

Melanocyte

What risk factor MUST be present for a pressure injury to develop? Mobility/activity limitations Moisture Nutritional impairment Poor tissue perfusion

Mobility/activity limitations

A patient presents with a purplish rash on the skin that turns blue-gray with fluid-filled blisters over the course of hours. What is the MOST likely etiology of this wound? Abscess Calciphylaxis Necrotizing fasciitis Pemphigus

Necrotizing fasciitis

During the inflammatory phase of full-thickness wound healing, which cell arrives first to kill bacteria and decontaminate the wound? Growth factor Macrophage Neutrophil Platelet

Neutrophil

What is one factor present in chronic wounds that can delay or stop wound healing? Increased blood perfusion Low levels of proteases No initial acute bleeding event Reduced levels of inflammation

No initial acute bleeding event

What agent neutralizes silver nitrate? Dakin's solution Normal saline Sterile water Tap water

Normal saline

What is the most common location for pressure injuries in infants and toddlers? Heel Occiput Sacrum Trochanter

Occiput

What types of cancers are MOST often sites of extension for fungating malignant wounds? Colon and vaginal Liver and pancreatic Lung and skin Oral and breast

Oral and breast

What is the best containment method for high output fistulas with odor? Calcium alginates Charcoal dressings Colostomy caps Ostomy pouching

Ostomy pouching

What does a body mass index (BMI) of 28.8 indicate? Normal weight Obese Overweight Underweight

Overweight

A neuropathic diabetic foot ulcer is MOST likely to occur at which site? Malleolar area Medial lower leg Plantar aspect of foot Tips of the toes

Plantar aspect of foot

Hemostasis is initiated when: Fibroblasts encounter platelets in the bloodstream. Platelets encounter collagen in injured tissues. Pro-inflammatory cytokines and growth factors are released. The extracellular matrix is absent or diminished.

Platelets encounter collagen in injured tissues.

What does pale pink coloration in a wound bed signify? Biofilm Infection Poor blood flow Wound chronicity

Poor blood flow

What type of wound closure has a faster rate of healing? Delayed primary intention Primary intention Secondary intention Tertiary intention

Primary intention

What type of wound closure is used for surgical incisions? Delayed primary intention Primary intention Secondary intention Tertiary intention

Primary intention

Angiogenesis occurs during which phase of wound healing? Hemostasis Inflammatory Maturation Proliferative

Proliferative

In wound healing, during which phase is the wound re-epithelialized or closed? Hemostasis phase Inflammatory phase Maturation phase Proliferative phase

Proliferative phase

What function of the skin does the acid mantle provide? Immunity Metabolism Protection Thermoregulation

Protection

What is a function of the extracellular matrix in the dermis? Produces cholesterol and Vitamin D Produces collagen and elastin Provides structural support for cells Secures the dermis to the epidermis

Provides structural support for cells

Evidence-based wound care helps ensure: Patient adherence to recommendations Quality and effectiveness in wound care The ability to bill for services Wound care supplies are on a formulary

Quality and effectiveness in wound care

What type of tissue is normally present during the proliferative phase of full-thickness wound healing? Hypergranulation Muscle or fascia Red granulation Slough or eschar

Red granulation

What effect does uncontrolled blood glucose levels have on wound healing? Decreases the inflammatory phase Improves epithelial migration Increases cytokine and growth factor signaling Reduces collagen synthesis

Reduces collagen synthesis

A patient has numerous small red macules surrounding a main lesion. What term would you use to describe this configuration? Annular Linear Satellite Zosteriform

Satellite

Excoriation in the perineum is caused by: Friction Moisture Pressure Scratching

Scratching

What type of wound closure has a higher risk for infection and recurrence? Delayed primary intention Primary intention Secondary intention Tertiary intention

Secondary intention

A wound has thin, watery, pale red exudate draining. How would you describe this? Sanguineous exudate Seropurulent exudate Serosanguineous exudate Serous exudate

Serosanguineous exudate

What intervention is considered the gold standard for tissue management of peri-wound hyperkeratosis in diabetic foot ulcers? Autolytic debridement Chemical cauterization Enzymatic debridement Sharp debridement

Sharp debridement

What type of force causes undermining and tunneling in a pressure injury? Friction Moisture Pressure Shear

Shear

A patient presents with an ulcer to the medial malleolus with punched out raised margins and a deep base. The wound bed has extensive necrotic tissue with extreme pain at the site. What is the MOST likely etiology of this wound? Arterial ulcer Necrotizing fasciitis Sickle cell ulceration Venous ulcer

Sickle cell ulceration

What topical antimicrobial product is indicated as an adjunct for the prevention and treatment of wound sepsis in patients with second- and third-degree burns? Cadexomer iodine Dialkylcarbamoyl chloride (DACC) Gentian violet and methylene blue Silver sulfadiazine

Silver sulfadiazine

What type of cleanser should never be used on open wounds? Skin cleansers Sterile water Surfactant cleansers Tap water

Skin cleansers

A wound has yellow, moist, stringy tissue present. What type of tissue does this describe? Granulation tissue Slough tissue Subcutaneous tissue Unstable eschar

Slough tissue

When is debridement contraindicated? Presence of a large amount of slough Presence of suspected or confirmed biofilm Stable eschar on a heel Unstable eschar with symptoms of infection

Stable eschar on a heel

What pressure injury stage involves full-thickness tissue loss involving epidermis, dermis, and into but not through subcutaneous fat? Stage 1 Stage 2 Stage 3 Stage 4

Stage 3

What type of underlying tissue is pale yellow and waxy? Cartilage Fascia Muscle Subcutaneous

Subcutaneous

A patient presents with a burn characterized by large blisters, edema, and pain. What burn classification does this represent? Deep partial-thickness Full-thickness Superficial Superficial partial-thickness

Superficial partial-thickness

What are the three parameters assessed when using the PUSH tool? Location, shape, and tissue type Stage, tissue type, and exudate amount Surface area, exudate amount, and tissue type Surface area, wound edges, and tissue type

Surface area, exudate amount, and tissue type

You are working with a new patient who is demonstrating non-adherence with the treatment regimen. What is the FIRST step you should take? Ask another nurse, physician, or professional to care for this patient. Change the treatment plan to be easier for the patient to follow. Talk to the patient about the reasons they are not adhering to the plan. Tell the patient you will discharge them if they do not follow the plan.

Talk to the patient about the reasons they are not adhering to the plan.

What does the distribution of a lesion describe? The clinical arrangement of lesions The form or structure of a lesion The pigmentation of a lesion The shape or outline of the lesion

The clinical arrangement of lesions

What function of the skin does vasoconstriction and vasodilation provide? Immunity Metabolism Protection Thermoregulation

Thermoregulation

Wounds closed by tertiary intention allow: Time for albumin level to be assessed. Time for infection to resolve. Time for the surgeon to perform the surgery. Time to obtain patient authorization.

Time for infection to resolve.

What is the function of the platelet in wound healing? To activate the extracellular matrix to form new blood vessels To aggregate and activate the red blood cell To aggregate and attract fibrin to form a clot To attract neutrophils and macrophages

To aggregate and attract fibrin to form a clot

What is the gold standard for offloading with diabetic foot ulcers? Crutches Heel suspension boots Total contact cast Walkers

Total contact cast

According to the ISTAP Skin Tear Classification, what type of skin tear results in a partial flap loss? Type 1 Type 2 Type 3 Type 4

Type 2

What term can be used to describe the wound edges when undermining is noted? Attached Defined Unattached Undefined

Unattached

Which tip is helpful when teaching patients about the application of compression stockings? Apply a moisturizer before application. Apply half way up the calf and rotate into position. Apply the stockings at night when edema is at its greatest. Use a stocking donner to aid in application.

Use a stocking donner to aid in application.

All of the following are effective patient education techniques EXCEPT: Ask for return demonstration. Break the material into manageable pieces. Schedule teaching sessions at frequent intervals. Use medical terminology.

Use medical terminology.

One function of the skin is to produce which vitamin? Vitamin B Vitamin C Vitamin D Vitamin K

Vitamin D

A wound assessment should occur at least: 2x/week Daily Monthly Weekly

Weekly

When using the PQRST mnemonic, what question would you ask to assess the "Q" portion? What causes the pain? What does the pain feel like? When did the pain start? Where is the pain located?

What does the pain feel like?

When would it be most appropriate to obtain a wound specimen collection? In an acute wound without signs of infection When an infected wound is responding to antimicrobial treatment When spreading or systemic infection is suspected When the wound has an increase in serous drainage

When spreading or systemic infection is suspected

When would autolytic debridement be indicated? In immunocompromised patients With extensive necrotic tissue With minimal to moderate necrotic tissue With undermining or sinus tracts

With minimal to moderate necrotic tissue

When does epithelial resurfacing of the incision occur after surgery? Within 1-2 days Within 2-3 days Within 4-6 days Within 7-10 days

Within 2-3 days