FLORIDA BOARD OF NURSING CERTIFIED
WOUND CARE NURSE EXAM WITH ACTUAL
QUESTIONS AND VERIFIED ANSWERS,
PLUS EXPLAINED RATIONALES/EXPERT
VERIFIED FOR GUARANTEED 100% PASS
2026/LATEST UPDATE/INSTANT
DOWNLOAD PDF
1. A 78-year-old immobile patient has a sacral wound measuring 4
cm × 3 cm × 0.4 cm. The wound bed contains approximately 60%
yellow slough and 40% red granulation tissue. No exposed fascia,
muscle, tendon, cartilage, or bone is visible. Which pressure-injury
stage is most appropriate?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: B. Stage 3
Rationale: A Stage 3 pressure injury involves full-thickness skin loss
in which adipose tissue and granulation tissue may be visible. Slough
may be present, but the extent of tissue destruction is not completely
obscured. Because the wound depth and tissue involvement can be
assessed and no deeper structures are exposed, Stage 3 is appropriate.
Stage 2 involves partial-thickness skin loss without slough, whereas
Stage 4 involves exposed or directly palpable deeper structures. A
wound is classified as unstageable when the extent of tissue damage
cannot be confirmed because it is completely obscured by slough or
eschar.
1
,2. A patient with a heel wound has intact, dry, adherent black
eschar. The heel is warm, without erythema, drainage, fluctuance,
or other signs of infection. What is the most appropriate initial
management?
A. Immediately sharply debride the eschar
B. Apply a wet-to-dry dressing twice daily
C. Leave the stable eschar intact and offload the heel
D. Irrigate the eschar aggressively with hydrogen peroxide
Answer: C. Leave the stable eschar intact and offload the heel
Rationale: Stable, dry, adherent eschar on the heel without erythema,
fluctuance, drainage, or other evidence of infection should generally
be left intact because it may serve as a biologic cover. The priority is
pressure redistribution and heel offloading. Aggressive debridement
can expose deeper tissue unnecessarily and potentially create a larger
wound. Hydrogen peroxide can damage viable tissue and is not
appropriate for routine wound-bed management.
3. A patient develops a localized area of intact, nonblanchable
erythema over the sacrum. The skin is warmer than surrounding
tissue and the patient reports tenderness. Which finding most
strongly supports Stage 1 pressure injury?
A. Full-thickness tissue loss
B. Visible adipose tissue
C. Intact skin with nonblanchable erythema
D. Exposed fascia
Answer: C. Intact skin with nonblanchable erythema
Rationale: Stage 1 pressure injury is characterized by intact skin with
localized nonblanchable erythema. Changes in temperature, tissue
consistency, sensation, or pain can accompany the injury. Stage 1
2
,should be recognized early because progression can occur rapidly if
pressure is not relieved. Visible adipose tissue indicates deeper tissue
loss, while exposed fascia indicates Stage 4 injury.
4. A patient with a diabetic foot ulcer has a plantar wound with
exposed tendon. Which characteristic most directly indicates a deep
ulcer requiring urgent specialist-level evaluation?
A. Mild surrounding callus
B. Serous drainage
C. Exposed tendon
D. Wound diameter of 0.5 cm
Answer: C. Exposed tendon
Rationale: Exposure of tendon indicates significant tissue destruction
and a deep wound with substantial risk for infection, impaired
function, and possible deeper extension. Diabetic foot wounds require
assessment of perfusion, neuropathy, infection, pressure distribution,
and potential bone involvement. A small surface diameter does not
exclude significant depth or severity.
5. A patient with a venous leg ulcer has edema, hemosiderin
deposition, lipodermatosclerosis, and a shallow irregularly shaped
wound near the medial malleolus. Which intervention is generally
central to management when significant arterial disease has been
excluded?
A. Long-term complete bed rest
B. Compression therapy
C. Routine systemic antibiotics
D. Daily application of povidone-iodine to the wound
Answer: B. Compression therapy
3
, Rationale: Venous hypertension contributes substantially to venous
leg-ulcer development and delayed healing. Compression therapy is a
cornerstone of treatment when arterial perfusion is adequate. It helps
reduce edema and venous hypertension. Systemic antibiotics are not
routinely indicated without clinical infection, and prolonged bed rest
can worsen mobility and venous stasis.
6. A patient with a lower-extremity ulcer has an ankle-brachial
index of 0.42. Which action is most appropriate before initiating
standard high-level compression therapy?
A. Begin high compression immediately
B. Apply compression and reassess in one month
C. Obtain vascular evaluation because significant arterial disease is
suspected
D. Increase compression because low ABI indicates severe venous
congestion
Answer: C. Obtain vascular evaluation because significant arterial
disease is suspected
Rationale: An ABI of 0.42 indicates significant arterial perfusion
impairment. Standard high compression may compromise already
limited arterial blood flow and potentially cause tissue ischemia. The
patient requires vascular assessment and an individualized
compression strategy rather than routine high compression. ABI
interpretation must also consider conditions such as diabetes and
medial arterial calcification, which can make measurements
unreliable.
4
WOUND CARE NURSE EXAM WITH ACTUAL
QUESTIONS AND VERIFIED ANSWERS,
PLUS EXPLAINED RATIONALES/EXPERT
VERIFIED FOR GUARANTEED 100% PASS
2026/LATEST UPDATE/INSTANT
DOWNLOAD PDF
1. A 78-year-old immobile patient has a sacral wound measuring 4
cm × 3 cm × 0.4 cm. The wound bed contains approximately 60%
yellow slough and 40% red granulation tissue. No exposed fascia,
muscle, tendon, cartilage, or bone is visible. Which pressure-injury
stage is most appropriate?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: B. Stage 3
Rationale: A Stage 3 pressure injury involves full-thickness skin loss
in which adipose tissue and granulation tissue may be visible. Slough
may be present, but the extent of tissue destruction is not completely
obscured. Because the wound depth and tissue involvement can be
assessed and no deeper structures are exposed, Stage 3 is appropriate.
Stage 2 involves partial-thickness skin loss without slough, whereas
Stage 4 involves exposed or directly palpable deeper structures. A
wound is classified as unstageable when the extent of tissue damage
cannot be confirmed because it is completely obscured by slough or
eschar.
1
,2. A patient with a heel wound has intact, dry, adherent black
eschar. The heel is warm, without erythema, drainage, fluctuance,
or other signs of infection. What is the most appropriate initial
management?
A. Immediately sharply debride the eschar
B. Apply a wet-to-dry dressing twice daily
C. Leave the stable eschar intact and offload the heel
D. Irrigate the eschar aggressively with hydrogen peroxide
Answer: C. Leave the stable eschar intact and offload the heel
Rationale: Stable, dry, adherent eschar on the heel without erythema,
fluctuance, drainage, or other evidence of infection should generally
be left intact because it may serve as a biologic cover. The priority is
pressure redistribution and heel offloading. Aggressive debridement
can expose deeper tissue unnecessarily and potentially create a larger
wound. Hydrogen peroxide can damage viable tissue and is not
appropriate for routine wound-bed management.
3. A patient develops a localized area of intact, nonblanchable
erythema over the sacrum. The skin is warmer than surrounding
tissue and the patient reports tenderness. Which finding most
strongly supports Stage 1 pressure injury?
A. Full-thickness tissue loss
B. Visible adipose tissue
C. Intact skin with nonblanchable erythema
D. Exposed fascia
Answer: C. Intact skin with nonblanchable erythema
Rationale: Stage 1 pressure injury is characterized by intact skin with
localized nonblanchable erythema. Changes in temperature, tissue
consistency, sensation, or pain can accompany the injury. Stage 1
2
,should be recognized early because progression can occur rapidly if
pressure is not relieved. Visible adipose tissue indicates deeper tissue
loss, while exposed fascia indicates Stage 4 injury.
4. A patient with a diabetic foot ulcer has a plantar wound with
exposed tendon. Which characteristic most directly indicates a deep
ulcer requiring urgent specialist-level evaluation?
A. Mild surrounding callus
B. Serous drainage
C. Exposed tendon
D. Wound diameter of 0.5 cm
Answer: C. Exposed tendon
Rationale: Exposure of tendon indicates significant tissue destruction
and a deep wound with substantial risk for infection, impaired
function, and possible deeper extension. Diabetic foot wounds require
assessment of perfusion, neuropathy, infection, pressure distribution,
and potential bone involvement. A small surface diameter does not
exclude significant depth or severity.
5. A patient with a venous leg ulcer has edema, hemosiderin
deposition, lipodermatosclerosis, and a shallow irregularly shaped
wound near the medial malleolus. Which intervention is generally
central to management when significant arterial disease has been
excluded?
A. Long-term complete bed rest
B. Compression therapy
C. Routine systemic antibiotics
D. Daily application of povidone-iodine to the wound
Answer: B. Compression therapy
3
, Rationale: Venous hypertension contributes substantially to venous
leg-ulcer development and delayed healing. Compression therapy is a
cornerstone of treatment when arterial perfusion is adequate. It helps
reduce edema and venous hypertension. Systemic antibiotics are not
routinely indicated without clinical infection, and prolonged bed rest
can worsen mobility and venous stasis.
6. A patient with a lower-extremity ulcer has an ankle-brachial
index of 0.42. Which action is most appropriate before initiating
standard high-level compression therapy?
A. Begin high compression immediately
B. Apply compression and reassess in one month
C. Obtain vascular evaluation because significant arterial disease is
suspected
D. Increase compression because low ABI indicates severe venous
congestion
Answer: C. Obtain vascular evaluation because significant arterial
disease is suspected
Rationale: An ABI of 0.42 indicates significant arterial perfusion
impairment. Standard high compression may compromise already
limited arterial blood flow and potentially cause tissue ischemia. The
patient requires vascular assessment and an individualized
compression strategy rather than routine high compression. ABI
interpretation must also consider conditions such as diabetes and
medial arterial calcification, which can make measurements
unreliable.
4
