WND 580 TEST PAPER ANSWERS AND QUESTIONS
SET A+
✔✔Mrs. Jones has an ulcer located on the dorsal surface of the third toe on the left foot.
The ulcer is 1 cm in diameter, with a dry, pale pink wound bed. She reports significant
pain in the ulcer and denies any history of diabetes. What is the MOST likely cause of
this ulcer?
a. Venous hypertension.
b. Neuropathy.
c. Pressure.
d. Arterial insufficiency. - ✔✔d. Arterial insufficiency.
✔✔The wound nurse is providing discharge education to a patient who suffered a deep
partial thickness burn to their lower extremity. What intervention would be most
appropriate in the plan of care?
a. Topical triple antibiotic ointment.
b. Moisturizers and OTC antihistamines.
c. Application of ice packs every 2 hours for 10 minutes.
d. Daily soaking in tub with disinfectant. - ✔✔b. Moisturizers and OTC antihistamines.
✔✔Lymphedema is the accumulation of:
a. Platelet rich fluid in the soft tissue.
b. Protein rich fluid in the soft tissue.
c. Cytokine rich fluid in the soft tissue.
d. Inflammatory cells in the soft tissue. - ✔✔b. Protein rich fluid in the soft tissue.
✔✔What diagnostic test is considered the "Gold Standard" for diagnosing LEVD (lower
extremity venous disease)?
a. ABI (ankle brachial index).
b. TcPo2 (Transcutaneous oxygen pressure measurement).
c. Duplex ultrasound.
,d. Segmental limb pressure. - ✔✔c. Duplex ultrasound.
✔✔Mr. Best has been diagnosed with lower extremity arterial disease (LEAD). What
risk factor for arterial disease may have played the greatest role in atherosclerosis
development?
a. Alcoholism.
b. Diabetes mellitus.
c. Sedentary lifestyle.
d. Hypothyroidism. - ✔✔b. Diabetes mellitus.
✔✔You are observing the limbs of a new patient and note that one limb has brawny
non-pitting edema from the toes to groin and positive Stemmer sign while the other is
without edema and no distortion in the leg shape. What type of disorder is this patient
most likely suffering from?
a. Venous disease.
b. Lipedema.
c. Lymphedema.
d. Dependent edema. - ✔✔c. Lymphedema.
✔✔Mr. Benn's venous ulcers have now resolved completely. You have fitted him with
proper below the knee compression stockings. Your discharge instructions include
which of the following?
a. Do not remove stockings at bedtime, only when showering or bathing.
b. Apply stocking upon rising in the morning.
c. Launder the stockings at least weekly.
d. Do not perform ankle exercises while wearing the stockings. - ✔✔b. Apply stocking
upon rising in the morning.
✔✔You are providing some patient education for a patient at risk for a neuropathic foot
ulcer in obtaining proper footwear, which of the following is the MOST important factor
when selecting proper foot wear?
a. Both feet should be measured, and shoes sized to the smaller foot.
b. Shoes should be sized in the afternoon to accommodate foot edema.
c. Patients should not stand when being sized for new shoes.
d. Allow for 1/8th inch space beyond the longest toe. - ✔✔b. Shoes should be sized in
the afternoon to accommodate foot edema.
✔✔The wound care nurse is evaluating an obese patient with a dehiscent surgical
wound following an abdominal hernia repair with biological mesh. Wound base has an
adherent slough without evidence of granulation tissue. The wound nurse recommends
the following initial topical wound management?
, a. Collagen product to stimulate granulation
b. Enzymatic debridement ointment (collagenase)
c. Short term use of sodium hypochlorite 0.125%
d. Irrigate wound with at least 500-1000 mL normal saline - ✔✔d. Irrigate wound with at
least 500-1000 mL normal saline
✔✔An elderly female developed a dehisced wound following abdominal surgery for a
bowel obstruction. Which of the following conditions BEST explains what placed her at
risk for developing a wound dehiscence?
a. Blood glucose levels ranging from 90 to 150.
b. History of radiation in the surgical field.
c. A prealbumin level of 28.
d. No postop dressing used. - ✔✔b. History of radiation in the surgical field.
✔✔The wound nurse is evaluating a homecare patient reporting on new onset of terrible
right thigh pain and flu like symptoms. The nurse notes spreading redness to the thigh,
with skin blisters/bullae and crepitus upon palpation as well as a dusk blue-gray
appearance. What is the most likely cause of this and what are the next intervention
steps?
a. Necrotizing Fasciitis, call 911 for immediate evaluation.
b. Toxic Epidermal Necrolysis (TEN), refer to primary care provider.
c. Graft versus Host Disease (GVHD), refer to oncologist.
d. Staphylococcal Scalded Skin Syndrome (SSSS), call 911 for immediate evaluation. -
✔✔a. Necrotizing Fasciitis, call 911 for immediate evaluation.
✔✔Which of the following causes of massive tissue loss is most commonly associated
with a severe drug reaction?
a. Epidermolysis bullosa (EB).
b. Toxic Epidermal Necrolysis (TEN).
c. Graft versus Host Disease (GVHD).
d. Staphylococcal Scalded Skin Syndrome (SSSS). - ✔✔b. Toxic Epidermal Necrolysis
(TEN).
✔✔The nursing staff calls you because a patient suffered an extravasation of
Vancomycin at a peripheral IV site, your immediate instructions are to:
a. Call the surgeon to schedule an immediate surgical debridement and skin grafting.
b. Apply pressure to the IV site for 30 minutes.
c. Flush IV site with Normal Saline and apply warm compress to site.
d. Recommend topical wound therapy once residual drug is aspirated. - ✔✔d.
Recommend topical wound therapy once residual drug is aspirated.
SET A+
✔✔Mrs. Jones has an ulcer located on the dorsal surface of the third toe on the left foot.
The ulcer is 1 cm in diameter, with a dry, pale pink wound bed. She reports significant
pain in the ulcer and denies any history of diabetes. What is the MOST likely cause of
this ulcer?
a. Venous hypertension.
b. Neuropathy.
c. Pressure.
d. Arterial insufficiency. - ✔✔d. Arterial insufficiency.
✔✔The wound nurse is providing discharge education to a patient who suffered a deep
partial thickness burn to their lower extremity. What intervention would be most
appropriate in the plan of care?
a. Topical triple antibiotic ointment.
b. Moisturizers and OTC antihistamines.
c. Application of ice packs every 2 hours for 10 minutes.
d. Daily soaking in tub with disinfectant. - ✔✔b. Moisturizers and OTC antihistamines.
✔✔Lymphedema is the accumulation of:
a. Platelet rich fluid in the soft tissue.
b. Protein rich fluid in the soft tissue.
c. Cytokine rich fluid in the soft tissue.
d. Inflammatory cells in the soft tissue. - ✔✔b. Protein rich fluid in the soft tissue.
✔✔What diagnostic test is considered the "Gold Standard" for diagnosing LEVD (lower
extremity venous disease)?
a. ABI (ankle brachial index).
b. TcPo2 (Transcutaneous oxygen pressure measurement).
c. Duplex ultrasound.
,d. Segmental limb pressure. - ✔✔c. Duplex ultrasound.
✔✔Mr. Best has been diagnosed with lower extremity arterial disease (LEAD). What
risk factor for arterial disease may have played the greatest role in atherosclerosis
development?
a. Alcoholism.
b. Diabetes mellitus.
c. Sedentary lifestyle.
d. Hypothyroidism. - ✔✔b. Diabetes mellitus.
✔✔You are observing the limbs of a new patient and note that one limb has brawny
non-pitting edema from the toes to groin and positive Stemmer sign while the other is
without edema and no distortion in the leg shape. What type of disorder is this patient
most likely suffering from?
a. Venous disease.
b. Lipedema.
c. Lymphedema.
d. Dependent edema. - ✔✔c. Lymphedema.
✔✔Mr. Benn's venous ulcers have now resolved completely. You have fitted him with
proper below the knee compression stockings. Your discharge instructions include
which of the following?
a. Do not remove stockings at bedtime, only when showering or bathing.
b. Apply stocking upon rising in the morning.
c. Launder the stockings at least weekly.
d. Do not perform ankle exercises while wearing the stockings. - ✔✔b. Apply stocking
upon rising in the morning.
✔✔You are providing some patient education for a patient at risk for a neuropathic foot
ulcer in obtaining proper footwear, which of the following is the MOST important factor
when selecting proper foot wear?
a. Both feet should be measured, and shoes sized to the smaller foot.
b. Shoes should be sized in the afternoon to accommodate foot edema.
c. Patients should not stand when being sized for new shoes.
d. Allow for 1/8th inch space beyond the longest toe. - ✔✔b. Shoes should be sized in
the afternoon to accommodate foot edema.
✔✔The wound care nurse is evaluating an obese patient with a dehiscent surgical
wound following an abdominal hernia repair with biological mesh. Wound base has an
adherent slough without evidence of granulation tissue. The wound nurse recommends
the following initial topical wound management?
, a. Collagen product to stimulate granulation
b. Enzymatic debridement ointment (collagenase)
c. Short term use of sodium hypochlorite 0.125%
d. Irrigate wound with at least 500-1000 mL normal saline - ✔✔d. Irrigate wound with at
least 500-1000 mL normal saline
✔✔An elderly female developed a dehisced wound following abdominal surgery for a
bowel obstruction. Which of the following conditions BEST explains what placed her at
risk for developing a wound dehiscence?
a. Blood glucose levels ranging from 90 to 150.
b. History of radiation in the surgical field.
c. A prealbumin level of 28.
d. No postop dressing used. - ✔✔b. History of radiation in the surgical field.
✔✔The wound nurse is evaluating a homecare patient reporting on new onset of terrible
right thigh pain and flu like symptoms. The nurse notes spreading redness to the thigh,
with skin blisters/bullae and crepitus upon palpation as well as a dusk blue-gray
appearance. What is the most likely cause of this and what are the next intervention
steps?
a. Necrotizing Fasciitis, call 911 for immediate evaluation.
b. Toxic Epidermal Necrolysis (TEN), refer to primary care provider.
c. Graft versus Host Disease (GVHD), refer to oncologist.
d. Staphylococcal Scalded Skin Syndrome (SSSS), call 911 for immediate evaluation. -
✔✔a. Necrotizing Fasciitis, call 911 for immediate evaluation.
✔✔Which of the following causes of massive tissue loss is most commonly associated
with a severe drug reaction?
a. Epidermolysis bullosa (EB).
b. Toxic Epidermal Necrolysis (TEN).
c. Graft versus Host Disease (GVHD).
d. Staphylococcal Scalded Skin Syndrome (SSSS). - ✔✔b. Toxic Epidermal Necrolysis
(TEN).
✔✔The nursing staff calls you because a patient suffered an extravasation of
Vancomycin at a peripheral IV site, your immediate instructions are to:
a. Call the surgeon to schedule an immediate surgical debridement and skin grafting.
b. Apply pressure to the IV site for 30 minutes.
c. Flush IV site with Normal Saline and apply warm compress to site.
d. Recommend topical wound therapy once residual drug is aspirated. - ✔✔d.
Recommend topical wound therapy once residual drug is aspirated.
