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Wound Care Assessment and Management: Questions and Answers for WOCN Exam Preparation, Exams of Nursing

A comprehensive set of questions and answers related to wound care assessment and management, covering topics such as etiologic factors, systemic factors, wound healing phases, topical therapy, nutrition, perfusion, immunosuppression, comorbidities, skin anatomy, skin problems, and prevention strategies. It is a valuable resource for wocn exam preparation, offering insights into key concepts and clinical considerations.

Typology: Exams

2024/2025

Available from 04/06/2025

catewilliams-smith
catewilliams-smith 🇺🇸

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WOCN Wound Exam Question With Verified
Solution 2025-2026
Goals of wound assessment - ✔✔1. Determine etiologic factors
2. Assess systemic factors/comorbidities
3. Assess wound to determine phase of healing
4. Determine goals of topical therapy
Why does hyperglycemia affect wound healing? - ✔✔Impairs leukocyte function and negatively
impacts collagen syntehesis, development of tensile strength, epithelial resurfacing
What BG parameters should be maintained for wound healing? - ✔✔BG <180 for leukocyte
function; <140 for healing
A1C <7 for most, <8 if hx of severe hypoglycemia, advanced comorbidities, limited life
expectancy
Why is nutrition relevant to wound healing? - ✔✔Muscle or SubQ wasting increases risk of
pressure/shear damage
malnourished pt unable to synthesize and cross-link collagen normally
protein deficiency increases risk of infection
What effect do low zinc levels have on wound healing? - ✔✔compromise collagen
synthesis/crosslinking
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WOCN Wound Exam Question With Verified

Solution 2025 - 2026

Goals of wound assessment - ✔✔1. Determine etiologic factors

  1. Assess systemic factors/comorbidities
  2. Assess wound to determine phase of healing
  3. Determine goals of topical therapy

Why does hyperglycemia affect wound healing? - ✔✔Impairs leukocyte function and negatively impacts collagen syntehesis, development of tensile strength, epithelial resurfacing

What BG parameters should be maintained for wound healing? - ✔✔BG <180 for leukocyte function; <140 for healing

A1C <7 for most, <8 if hx of severe hypoglycemia, advanced comorbidities, limited life expectancy

Why is nutrition relevant to wound healing? - ✔✔Muscle or SubQ wasting increases risk of pressure/shear damage

malnourished pt unable to synthesize and cross-link collagen normally

protein deficiency increases risk of infection

What effect do low zinc levels have on wound healing? - ✔✔compromise collagen synthesis/crosslinking

What amino acids are essential for collagen synthesis?

What is the effect of stress on these amino acids? - ✔✔Glutamine and l-arginine

Not adequately produced during times of physiologic stress

What weight trend suggests nutritional deficiency? - ✔✔Unplanned weight loss =>2.5% of usual weight in 30 days or =>10% within 180 days

BMI <18.

What serum albumin level indicates malnutrition? - ✔✔<3.5 g/dl

What serum transferrin level indicates malnutrition? - ✔✔<100mg/dl

What serum prealbumin level indicates malnutrition? - ✔✔<19.

What total lymphocyte count level indicates malnutrition? - ✔✔<

What are s/s of nutritional deficits? - ✔✔skin rashes, cracks in mucous membranes, edema, muscle and subQ tissue wasting, nonhealing wounds, dry/pluckable hair, dry flaky itchy skin

What is the suggested caloric intake? - ✔✔30-35 cal/kg body weight

What is the suggested protein intake? - ✔✔1.25-1.5 g/kg body weight

Stratum spinosum - desmosomes (cell to cell junctions)

Stratum germinativum - dermal-epidermal junction

What is the Basement Membrane Zone? - ✔✔Dermal-epidermal junction

What are the components of the dermis? - ✔✔Papillary dermis: papillae interlock with rete ridges, capillary loops, sensitive to point pressure

Reticular dermis: mostly type 1 collagen, vasculars, and lymphatics

What structures of the skin can regenerate? - ✔✔Epidermis and parts of the dermis

What structures of the skin heal by scar formation? - ✔✔Epidermal appendages, Subcutaneous tissue/fascia/muscle

How is newborn skin different? - ✔✔No scars up to 2nd trimester

30% thinner skin

Faster epidermal turnover

How is premature infant skin different? - ✔✔Very thin, increased fluid loss, functional stratum corneum at 30-32 weeks

What problems may arise with infant skin? - ✔✔increased permeability, increased MARSI risk, extravasation, diaper dermatitis

How do you mitigate MARSI risk in infants/elderly? - ✔✔avoid tape or use hydrocolloid base or silicone adhesive, no alcohol removers only mineral oil, petroleum, silicone (preferred), and citrus)

How do you mitigate extravasation in an infant? - ✔✔Hyaluronidase

OR

phentolamine if vasoconstrictor

How do you mitigate diaper dermatitis? - ✔✔Higher pH

Use petroleum base for mild erythema and zinc oxide for denuded skin

sever denudation - carboxymethylcellulose/petrolatum/zinc oxide (Ilex)

What bathing considerations must you take for premature infants? - ✔✔<30 weeks bathe with water only for 2 weeks

What are common issues with older skin? - ✔✔Thinner, collagen shrinks and causes wrinkles

Rete ridges and dermal papillae flatten - increased risk for tears/stripping

Reduced sebaceous and sweat glands - dry skin

Erratic/decreased melanin production

Decreased sensation - increased trauma risk

Loss of SubQ tissue - increased shear and decreased insulation

Increased malignant lesions - refer to derm

Who are humectants for? - ✔✔Only for xerosis - not for macerated and sometimes not for fragile skin

Which tissue layer is most susceptible to ischemic damage? - ✔✔Muscle/fascia layer

What is a macule - ✔✔Flat spot of color change less than 0.5cm in diameter

What is a papule - ✔✔Flat spot of color change greater than 0.5cm in diameter

What is a patch? - ✔✔Raised spot of color change less than 0.5cm in diameter

What is a plaque? - ✔✔Raised spot of color change greater than 0.5cm in diameter

What is a blister? - ✔✔Serous fluid trapped under skin less than 0.5cm in diameter

What is a bulla? - ✔✔Serous fluid trapped under skin greater than 0.5cm in diameter

What is erythema? - ✔✔Generalized redness

What is denudation? - ✔✔Loss of superficial skin layer

What is crusting? - ✔✔Scab of dried exudate of body fluid, blood, or pus

What is granulation? - ✔✔proliferating tissue made of capillary networks, collagen, and other connective substances

What is slough? - ✔✔Loose, stringy, nonviable tissue

What is eschar? - ✔✔Thick, leathery, necrotic tissue

What is undermining? - ✔✔Tissue destruction underlying intact skin along wound margins

What is tunneling? - ✔✔Area of tissue loss extending in any direction from edge of wound

What is the normal water content of the skin? - ✔✔10-15%

What is friction skin damage? - ✔✔Mechanical disruption of surface layer of skin

Where does friction skin damage occur? - ✔✔under restraints, blisters on heels, surface damage on butt

What precedes friction skin loss? - ✔✔Erythema, tenderness

How can you avoid skin tears? - ✔✔avoid tape

moisturize - supple skin

protect arms with wrap (ensure no compression)

pad bedrails, wheelchairs, etc

Gentle skin care/handling

What is topical treatment for skin tears? - ✔✔Type 1: cleanse, roll viable flap back and secure with steristrips

Type 2 and 3: cleanse with saline, dress with silicone adhesive foam, silicone contact layer + wrap gauze, solid glycerine gel dressing (low exudate), nonadherent gauze with wrap gauze, nonadherent polyurethane foam with wrap gauze

What is MARSI? - ✔✔Medical adhesive related skin injury

Erythema or other skin damage that persists 30 minutes plus after adhesive removal

How do you prevent MARSI? - ✔✔Avoid products that cause reaction

Consider liquid barrier films

Apply to dry skin without tension

Low and slow horizontal removal - support skin adjacent to peel line

Paper and silicone tapes are better

What special considerations exist for paper tape, acrylate adhesive? - ✔✔must be applied with firm pressure and adhesion increases over time

What is IAD? - ✔✔Incontinence associated dermatitis

External moisture - begins with inflammation and moves to skin loss

How do you prevent IAD? - ✔✔Toileting programs, containment devices, absorptive products with polymers to wick away from skin

What types of moisture barrier products exist? - ✔✔Petrolatum products

Dimethicone products

Zinc oxide

Alcohol free liquid barrier films

Why/when do you use petrolatum moisture barrier products? - ✔✔easy to apply and remove

thin layer to avoid transfer to brief/pad because it will interfere with absorption

Not adherent or protective with denudation or liquid stool

Why/when do you use dimethicone moisture barrier products? - ✔✔easy to apply/remove

non-occlusive - good for diaphoresis+incontinence

inadequate for denudation/liquid stool

How do you manage periwound MASD? - ✔✔appropriate dressings

Moisture barriers where adhesion is not a problem

What causes peristomal MASD? - ✔✔exposure to effluent and perspiration

How do you prevent peristomal MASD? - ✔✔secure pouching system

correctly size pouch

protection of peristomal skin

appropriate pouch change frequency

How do you manage peristomal MASD? - ✔✔treat denuded areas with pectin powder + alcohol free liquid barrier or hydrocolloid/foam dressing under patch

What causes pressure injuries? - ✔✔prolonged/intense pressure

shear force

reduced/compromised tissue tolerance

Why does prolonged/intense pressure cause pressure injuries? - ✔✔ischemia from occluded capillaries, edema and waste buildup from occluded lymph capillaries, reperfusion injury from thrombi formed during stasis, oxygen free radicals that damage vessel endothelial lining

Why does shear force cause pressure injuries? - ✔✔friction + gravity, angulation and disruption of blood vessels, irregular deep lesions

What types of reduced/compromised tissue tolerance contribute to pressure injuries? - ✔✔muscle wasting

loss of subq tissue

underlying vascular disease/edema/hypotension

hyperthermia

smoking

stress

pressure means time tolerance - ✔✔reduced

increased

What do redistribution surfaces do? - ✔✔reduce intensity of pressure

What does routine repositioning do? - ✔✔reduces time factor

restores blood and lymphatic flow and interstitial fluid to compromised area

What do conformable surfaces do? - ✔✔Minimize interstitial fluid shifts and minimize degree of capillary and lymph occlusion

How do you reduce shear? - ✔✔Limit HOB elevation

How do you manage deep tissue injuries? - ✔✔pressure redistribution and reduction of shear

no debridement until clear necrotic tissue

What are the braden scale score categories? - ✔✔9 or below - very high risk

10-12 high risk

13-14 moderate risk

15-18 at risk

What braden scale scores must you address? - ✔✔Any 2 or below

What are the braden scale categories? - ✔✔Sensory perception

Moisture

Activity

Mobility

Nutrition

Friction and Shear

How do you rank in the braden scale category sensory perception? - ✔✔1 - limited ability to feel pain over most of body

2 - limits ability to feel pain over 1/2 of body

3 - limits ability to feel pain in 1-2 extremities

4 - no impairment

How do you rank in the braden scale category moisture? - ✔✔1 - consistently moist - detected every time pt moved or turned

2 - skin often but not always moist - linens must be changed once a shift

3 - occasionally moist - extra linen change once a day

4 - rarely moist

How do you rank in the braden scale category activity? - ✔✔1 - bedfast

2 - chairfast

3 - walks occasionally for short distances with or without assistance

4 - walks frequently at least twice a day

How do you rank in the braden scale category mobility? - ✔✔1 - completely immobile - no changes in position

2 - Very limited - occasional slight changes

3 - frequent through slight changes

4 - major and frequent changes in position

How do you rank in the braden scale category nutrition? - ✔✔1 - NPO or clear liquids for more than 5 days; never eats a complete meal, rarely eats more than 1/2 of food offered

2 - generally eats 1/2 of food offered, receives less than optimum amt of tube feeding

3 - eats over half of most meals or gets most nutritional needs from TPN

4 - eats most of every meal, eats between meals, never refuses meal

How deep must air chambers be for alternating pressure surfaces? - ✔✔Air chambers must be at least 10cm in depth

What is air fluidized therapy? - ✔✔Surfaces that involve a tank filled wiht siliconized glass beads that create a fluid medium when air is forced through the beads

Provides very high level immersion and envelopment as well as high level air flow

What are the issues with air fluidized therapy? - ✔✔difficult to get patient out of bed and difficult to maintain head elevation

Not for cardio/respiratory issues or tube feedings

What is low air loss? - ✔✔low flow of air against the patient's skin designed to control skin heat and humidity

What is support surface active therapy? - ✔✔powered surface with air chambers that are alternately inflated and deflated according to defined cycle and not in response to patient's weight

What is support surface reactive therapy? - ✔✔surfaces that react to patient's weight by creating comfortable surface (foam, gel, water bed, air, sheepskin) no change in pressure points

What are the phases of partial thickness wound repair? - ✔✔1. inflammatory response

  1. epithelial cell proliferation and migration
  1. reestablishment of normal skin layers and skin thickness

What happens in the partial thickness inflammatory response? - ✔✔24 hours

erythema, edema, serous exudate

What happens in the epithelial cell proliferation and migration phase of partial thickness wound healing? - ✔✔may begin within 8 hours

Needs attachment of keratinocytes to wound bed and stimulation by growth factors

How do you promote epithelial cell proliferation? - ✔✔Clean, moist, healthy wound bed

Low bacterial counts

normal Blood glucose

normal amount of growth factors and MMPs

What occurs in epithelial cell proliferation and migration stage if there is dermal loss? - ✔✔ 5 days post-injury a layer of fluid separates epidermis from dermis

Blood vessels sprout

Collagen synthesis begins day 9 to 15 and extends into fluid layer, new epidermis collapses around new vessels and collagen to form rete ridges

What happens in the reestablishment of normal skin layers and skin thickness phase of partial thickness skin repair? - ✔✔when migrating epithelial cells make contact, migration ceases

Cells resume upward migration and differentiation