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GNUR 238 WOUND ASSESSMENT & NURSING
CARE ACTUAL EXAM
1. A clean surgical wound (CDC Class 1) is best described as:
A. A penetrating abdominal incision with spillage of gastric contents
B. An incision in sterile tissue with no infection and no entry into respiratory or
gastrointestinal tracts
C. A bite wound contaminated with saliva
D. A laceration with visible pus
Answer: B
Rationale: A Class 1 (clean) wound is an uninfected, usually closed, surgical wound not
involving the respiratory, alimentary, genital, or urinary tracts. It shows no signs of infection
or inflammation. By contrast, wounds with gross spillage of gut contents or obvious infection
would be contaminated or dirty (Classes III/IV)
Which term best describes a wound that contains multiplying bacteria without causing a host
immune response?
A. Contaminated wound
B. Infected wound
C. Colonized wound
D. Sterile wound
Answer: C
Rationale: Colonization refers to the presence and replication of microorganisms in a wound
without eliciting an immune response or overt infection signs. Contamination means some
bacteria are present but not multiplying significantly. Infection implies bacteria are invading
tissue and triggering an immune reaction.
2. A surgical wound that involves entry into the gastrointestinal tract under controlled
conditions is classified as:
A. Clean-contaminated (Class II)
B. Clean (Class I)
C. Contaminated (Class III)
D. Dirty-infected (Class IV)
Answer: A
Rationale: A Class II (clean-contaminated) wound involves controlled entry into the GI,
respiratory, genital, or urinary tracts without unusual contamination. These wounds have a
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higher infection risk than Class I but are not frankly infected. Class III (contaminated) implies a
major break in technique or gross spillage, and Class IV is already infected.
3. Which of the following best characterizes a contaminated wound (Class III)?
A. Closed abrasion with no signs of infection
B. Puncture wound from a sterile needle
C. Surgical incision with acute nonpurulent inflammation or accidental spillage of gut
contents
D. Laceration treated immediately and kept clean
Answer: C
Rationale: Contaminated (Class III) wounds include surgical incisions with a major break in
sterility or wounds resulting from acute nonpurulent inflammation, or an accidental spillage of
GI contents. They are not yet infected but have a high bacterial load, unlike Class II (clean-
contaminated) which is controlled entry.
4. A Class IV (dirty or infected) wound typically involves:
A. A fresh surgical incision with no inflammation
B. An intact epithelial scar
C. Traumatic injury with pus and devitalized tissue
D. A chronic ulcer being debrided
Answer: C
Rationale: Class IV (dirty/infected) wounds are grossly contaminated and usually infected. They
often come from inadequate care of traumatic wounds or from pus and necrotic tissue present
at the time of surgery. Class IV indicates loss of tissue vitality and high bacterial contamination.
2. Wound Documentation
6. In wound documentation, which of the following should NOT be routinely recorded?
A. Wound location on the body
B. Wound dimensions (length, width, depth)
C. Wound edges and tissue type (e.g., granulation, slough)
D. Patient’s favorite color
Answer: D
Rationale: Proper wound documentation includes location, size (length, width, depth), tissue
appearance, edges, undermining, and amount/type of exudate. Patient’s favorite color is
irrelevant to the clinical assessment. For example, length is measured head-to-toe and width
side-to-side.
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7. Which description correctly defines the tissue called granulation tissue?
A. A dry, black necrotic covering
B. Red, beefy tissue that bleeds easily
C. Thin, yellow fibrous debris
D. A callus-like thickening of skin
Answer: B
Rationale: Granulation tissue is healthy, beefy red, moist tissue that bleeds readily, indicating
active healing. It consists of new capillaries and fibroblasts. In contrast, slough or fibrinous
tissue is white/yellow and does not bleed, and eschar is black, dry, and nonviable.
8. Slough in a wound bed is best described as:
A. Fresh red granulating tissue
B. White to yellow nonviable tissue that does not bleed
C. Intact, non-blanching red skin
D. Thick green pus
Answer: B
Rationale: Slough is devitalized (necrotic) tissue appearing white or yellow, usually moist and
fibrous, and it does not bleed when touched. It must be distinguished from healthy granulation
(red, bleeds) and from purulent material.
9. When assessing exudate quantity, what term is used when drainage saturates more
than 75% of the dressing?
A. Minimal
B. Scant
C. Copious (large)
D. Moderate
Answer: C
Rationale: Exudate volume is described as none, scant, minimal, moderate, or large/copious.
Copious (large) means the wound is filled with fluid, with exudate covering more than 75% of
the bandage. “Scant” or “minimal” would cover a much smaller area.
10. The correct way to measure wound depth when tunnels or undermining are present is
to:
A. Measure only length and width, ignore depth
B. Use a sterile cotton-tipped applicator and a clock reference
C. Assume depth is equal to width if not visible
D. Estimate based on wound color
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Answer: B
Rationale: If a wound has tunneling or undermining, the depth should be assessed with a sterile
cotton-tipped applicator inserted into the tract, and documented using the clock-face method
(e.g., “tunnel at 3 o’clock, 2 cm deep”) . This ensures an objective measure of depth; guessing
or ignoring depth would be inaccurate.
3. Types of Wound Drainage
11. Serous exudate is typically characterized as:
A. Thick, yellow, and foul-smelling
B. Clear to pale yellow, thin, and watery
C. Bright red fresh blood
D. Pinkish, watery, mixed with serum
Answer: B
Rationale: Serous drainage is clear or pale yellow, thin, and watery plasma . It is a normal part
of healing (inflammatory stage) in small amounts. It is slightly thicker than water . Thick yellow
pus would be purulent; bright red blood is sanguineous; pinkish (serosanguineous) contains
some blood .
12. Purulent drainage from a wound most often appears:
A. Clear and odorless
B. Thin and pink
C. Thick, opaque, and tan/green/yellow
D. Watery and light yellow
Answer: C
Rationale: Purulent exudate is thick and opaque, with a yellow, tan, green, or brown color . It
usually has a foul odor and is never considered normal; it indicates infection or high bacterial
count . Thin, clear exudate is serous; pink-tinged (serosanguineous) contains blood .
13. Which statement about serosanguineous drainage is true?
A. It is always a sign of infection.
B. It is a mix of clear fluid and a small amount of blood.
C. It is thick and yellow, indicating pus.
D. It is the same as purulent exudate.
Answer: B
Rationale: Serosanguineous exudate contains both serous (clear) fluid and a small amount of
blood, giving it a pale pink or light red color . It is common in the inflammatory stage of healing
GNUR 238 WOUND ASSESSMENT & NURSING
CARE ACTUAL EXAM
1. A clean surgical wound (CDC Class 1) is best described as:
A. A penetrating abdominal incision with spillage of gastric contents
B. An incision in sterile tissue with no infection and no entry into respiratory or
gastrointestinal tracts
C. A bite wound contaminated with saliva
D. A laceration with visible pus
Answer: B
Rationale: A Class 1 (clean) wound is an uninfected, usually closed, surgical wound not
involving the respiratory, alimentary, genital, or urinary tracts. It shows no signs of infection
or inflammation. By contrast, wounds with gross spillage of gut contents or obvious infection
would be contaminated or dirty (Classes III/IV)
Which term best describes a wound that contains multiplying bacteria without causing a host
immune response?
A. Contaminated wound
B. Infected wound
C. Colonized wound
D. Sterile wound
Answer: C
Rationale: Colonization refers to the presence and replication of microorganisms in a wound
without eliciting an immune response or overt infection signs. Contamination means some
bacteria are present but not multiplying significantly. Infection implies bacteria are invading
tissue and triggering an immune reaction.
2. A surgical wound that involves entry into the gastrointestinal tract under controlled
conditions is classified as:
A. Clean-contaminated (Class II)
B. Clean (Class I)
C. Contaminated (Class III)
D. Dirty-infected (Class IV)
Answer: A
Rationale: A Class II (clean-contaminated) wound involves controlled entry into the GI,
respiratory, genital, or urinary tracts without unusual contamination. These wounds have a
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higher infection risk than Class I but are not frankly infected. Class III (contaminated) implies a
major break in technique or gross spillage, and Class IV is already infected.
3. Which of the following best characterizes a contaminated wound (Class III)?
A. Closed abrasion with no signs of infection
B. Puncture wound from a sterile needle
C. Surgical incision with acute nonpurulent inflammation or accidental spillage of gut
contents
D. Laceration treated immediately and kept clean
Answer: C
Rationale: Contaminated (Class III) wounds include surgical incisions with a major break in
sterility or wounds resulting from acute nonpurulent inflammation, or an accidental spillage of
GI contents. They are not yet infected but have a high bacterial load, unlike Class II (clean-
contaminated) which is controlled entry.
4. A Class IV (dirty or infected) wound typically involves:
A. A fresh surgical incision with no inflammation
B. An intact epithelial scar
C. Traumatic injury with pus and devitalized tissue
D. A chronic ulcer being debrided
Answer: C
Rationale: Class IV (dirty/infected) wounds are grossly contaminated and usually infected. They
often come from inadequate care of traumatic wounds or from pus and necrotic tissue present
at the time of surgery. Class IV indicates loss of tissue vitality and high bacterial contamination.
2. Wound Documentation
6. In wound documentation, which of the following should NOT be routinely recorded?
A. Wound location on the body
B. Wound dimensions (length, width, depth)
C. Wound edges and tissue type (e.g., granulation, slough)
D. Patient’s favorite color
Answer: D
Rationale: Proper wound documentation includes location, size (length, width, depth), tissue
appearance, edges, undermining, and amount/type of exudate. Patient’s favorite color is
irrelevant to the clinical assessment. For example, length is measured head-to-toe and width
side-to-side.
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7. Which description correctly defines the tissue called granulation tissue?
A. A dry, black necrotic covering
B. Red, beefy tissue that bleeds easily
C. Thin, yellow fibrous debris
D. A callus-like thickening of skin
Answer: B
Rationale: Granulation tissue is healthy, beefy red, moist tissue that bleeds readily, indicating
active healing. It consists of new capillaries and fibroblasts. In contrast, slough or fibrinous
tissue is white/yellow and does not bleed, and eschar is black, dry, and nonviable.
8. Slough in a wound bed is best described as:
A. Fresh red granulating tissue
B. White to yellow nonviable tissue that does not bleed
C. Intact, non-blanching red skin
D. Thick green pus
Answer: B
Rationale: Slough is devitalized (necrotic) tissue appearing white or yellow, usually moist and
fibrous, and it does not bleed when touched. It must be distinguished from healthy granulation
(red, bleeds) and from purulent material.
9. When assessing exudate quantity, what term is used when drainage saturates more
than 75% of the dressing?
A. Minimal
B. Scant
C. Copious (large)
D. Moderate
Answer: C
Rationale: Exudate volume is described as none, scant, minimal, moderate, or large/copious.
Copious (large) means the wound is filled with fluid, with exudate covering more than 75% of
the bandage. “Scant” or “minimal” would cover a much smaller area.
10. The correct way to measure wound depth when tunnels or undermining are present is
to:
A. Measure only length and width, ignore depth
B. Use a sterile cotton-tipped applicator and a clock reference
C. Assume depth is equal to width if not visible
D. Estimate based on wound color
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Answer: B
Rationale: If a wound has tunneling or undermining, the depth should be assessed with a sterile
cotton-tipped applicator inserted into the tract, and documented using the clock-face method
(e.g., “tunnel at 3 o’clock, 2 cm deep”) . This ensures an objective measure of depth; guessing
or ignoring depth would be inaccurate.
3. Types of Wound Drainage
11. Serous exudate is typically characterized as:
A. Thick, yellow, and foul-smelling
B. Clear to pale yellow, thin, and watery
C. Bright red fresh blood
D. Pinkish, watery, mixed with serum
Answer: B
Rationale: Serous drainage is clear or pale yellow, thin, and watery plasma . It is a normal part
of healing (inflammatory stage) in small amounts. It is slightly thicker than water . Thick yellow
pus would be purulent; bright red blood is sanguineous; pinkish (serosanguineous) contains
some blood .
12. Purulent drainage from a wound most often appears:
A. Clear and odorless
B. Thin and pink
C. Thick, opaque, and tan/green/yellow
D. Watery and light yellow
Answer: C
Rationale: Purulent exudate is thick and opaque, with a yellow, tan, green, or brown color . It
usually has a foul odor and is never considered normal; it indicates infection or high bacterial
count . Thin, clear exudate is serous; pink-tinged (serosanguineous) contains blood .
13. Which statement about serosanguineous drainage is true?
A. It is always a sign of infection.
B. It is a mix of clear fluid and a small amount of blood.
C. It is thick and yellow, indicating pus.
D. It is the same as purulent exudate.
Answer: B
Rationale: Serosanguineous exudate contains both serous (clear) fluid and a small amount of
blood, giving it a pale pink or light red color . It is common in the inflammatory stage of healing
