Emory Wound Exam 2 Wound Assessment
Cleansing Moist Wound Healing Official
Practice Exam Actual Exam 2026/2027 with
Detailed Rationales | Complete Exam-Style
Questions | Pass Guaranteed – A+ Graded
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SECTION 1: WOUND ASSESSMENT & DOCUMENTATION Q1 – Q10
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Question 1 of 50
A 62-year-old patient in the ICU has a sacral wound with 30% black, leathery tissue covering
the wound bed, 40% red beefy tissue, and 30% yellow stringy tissue. When documenting
tissue types, which description is most accurate?
A. 30% necrotic tissue, 40% beefy red tissue, 30% yellow stringy tissue
B. 30% eschar, 40% epithelial tissue, 30% slough
C. 30% eschar, 40% granulation tissue, 30% slough ✓ CORRECT
D. 30% necrotic tissue, 40% granulation tissue, 30% purulent drainage
Correct Answer: C
Rationale: Black leathery tissue is eschar, beefy red tissue with a granular appearance is
granulation tissue, and yellow stringy tissue is slough, which are the standardized terms
required for precise wound documentation. The term "necrotic tissue" is too vague because
both eschar and slough are types of necrotic tissue, and "purulent drainage" describes
exudate rather than a tissue type. Using specific terminology ensures clear interdisciplinary
communication and guides appropriate treatment decisions.
Question 2 of 50
A wound care nurse is assessing a 54-year-old patient's venous leg ulcer. The periwound skin
is white, soggy, and peeling at the edges. Which term best describes this finding?
A. Maceration ✓ CORRECT
B. Erythema
C. Induration
D. Hyperkeratosis
,Correct Answer: A
Rationale: Maceration presents as white, soggy, peeling skin caused by prolonged exposure
to moisture or exudate, commonly seen around heavily exuding wounds such as venous leg
ulcers. Erythema describes redness from inflammation, induration is hardened tissue, and
hyperkeratosis is thickened skin. Preventing maceration requires managing exudate with
appropriate absorbent dressings and protecting periwound skin with barrier products.
Question 3 of 50
During a wound irrigation procedure for a 45-year-old patient with a contaminated traumatic
wound, the nurse must select the appropriate pressure to cleanse the wound bed effectively
without causing tissue trauma. Which pressure range is recommended?
A. 1 to 5 psi
B. 4 to 15 psi ✓ CORRECT
C. 15 to 20 psi
D. 20 to 30 psi
Correct Answer: B
Rationale: Wound irrigation at 4 to 15 psi effectively removes debris and bacteria without
forcing solution into tissue or causing mechanical trauma to viable wound bed tissue.
Pressures below 4 psi are insufficient for cleansing contaminated wounds, while pressures
above 15 psi can drive bacteria deeper and damage granulation tissue. A 35-mL syringe with a
19-gauge needle or angiocatheter generates approximately 8 psi, which falls within the
recommended range.
Question 4 of 50
A 67-year-old patient with a diabetic foot ulcer has a wound photograph taken for
documentation. The nurse reviews the image and notes that the ruler is placed beside but not
in the same plane as the wound, and the flash creates a shadow across the wound bed. What
is the primary concern with this photograph?
A. The ruler placement does not affect measurement accuracy as long as it is visible
B. Shadowing improves contrast and makes tissue types easier to identify
C. The photograph should be taken without a ruler to avoid distracting from the wound
D. The ruler must be in the same plane as the wound, and shadowing obscures tissue detail ✓
CORRECT
Correct Answer: D
Rationale: Accurate wound photography requires placing the ruler in the same plane as the
wound surface to prevent parallax error that distorts measurements, and lighting must be
consistent without shadows to clearly visualize tissue types and wound characteristics.
Shadows obscure true color and tissue detail, while improper ruler placement leads to
, inaccurate size documentation. Standardized photography protocols ensure reliable
longitudinal comparison and legal documentation.
Question 5 of 50
A wound care nurse is evaluating a 71-year-old LTAC patient's sacral pressure injury. The
wound bed contains 100% bright red, beefy, granular tissue with small bumps that bleed easily
when touched. Which tissue type is predominant?
A. Granulation tissue ✓ CORRECT
B. Slough
C. Epithelial tissue
D. Eschar
Correct Answer: A
Rationale: Granulation tissue is characterized by its beefy red appearance, granular or bumpy
texture, and friability that causes easy bleeding upon contact, indicating healthy
vascularization and active wound healing. Slough is yellow, stringy, or moist necrotic tissue,
while eschar is black, brown, or tan leathery necrotic tissue. Epithelial tissue appears as pink,
translucent new skin migrating from wound edges or islands across the wound bed.
Question 6 of 50
A nurse is assessing a 58-year-old patient's surgical wound on postoperative day 5 and
observes thin, watery, pale red drainage saturating the dressing. How should this exudate be
documented?
A. Serous drainage
B. Serosanguineous drainage ✓ CORRECT
C. Sanguineous drainage
D. Purulent drainage
Correct Answer: B
Rationale: Serosanguineous drainage is thin, watery, and pale red or pink, containing both
serum and small amounts of blood, which is typical in the early inflammatory and
proliferative phases of healing. Serous drainage is clear and straw-colored, sanguineous
drainage is bright red and indicates active bleeding, and purulent drainage is thick, opaque,
and yellow, green, or tan indicating infection. Accurate exudate description guides dressing
selection and alerts clinicians to potential complications.
Question 7 of 50
Cleansing Moist Wound Healing Official
Practice Exam Actual Exam 2026/2027 with
Detailed Rationales | Complete Exam-Style
Questions | Pass Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: WOUND ASSESSMENT & DOCUMENTATION Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 62-year-old patient in the ICU has a sacral wound with 30% black, leathery tissue covering
the wound bed, 40% red beefy tissue, and 30% yellow stringy tissue. When documenting
tissue types, which description is most accurate?
A. 30% necrotic tissue, 40% beefy red tissue, 30% yellow stringy tissue
B. 30% eschar, 40% epithelial tissue, 30% slough
C. 30% eschar, 40% granulation tissue, 30% slough ✓ CORRECT
D. 30% necrotic tissue, 40% granulation tissue, 30% purulent drainage
Correct Answer: C
Rationale: Black leathery tissue is eschar, beefy red tissue with a granular appearance is
granulation tissue, and yellow stringy tissue is slough, which are the standardized terms
required for precise wound documentation. The term "necrotic tissue" is too vague because
both eschar and slough are types of necrotic tissue, and "purulent drainage" describes
exudate rather than a tissue type. Using specific terminology ensures clear interdisciplinary
communication and guides appropriate treatment decisions.
Question 2 of 50
A wound care nurse is assessing a 54-year-old patient's venous leg ulcer. The periwound skin
is white, soggy, and peeling at the edges. Which term best describes this finding?
A. Maceration ✓ CORRECT
B. Erythema
C. Induration
D. Hyperkeratosis
,Correct Answer: A
Rationale: Maceration presents as white, soggy, peeling skin caused by prolonged exposure
to moisture or exudate, commonly seen around heavily exuding wounds such as venous leg
ulcers. Erythema describes redness from inflammation, induration is hardened tissue, and
hyperkeratosis is thickened skin. Preventing maceration requires managing exudate with
appropriate absorbent dressings and protecting periwound skin with barrier products.
Question 3 of 50
During a wound irrigation procedure for a 45-year-old patient with a contaminated traumatic
wound, the nurse must select the appropriate pressure to cleanse the wound bed effectively
without causing tissue trauma. Which pressure range is recommended?
A. 1 to 5 psi
B. 4 to 15 psi ✓ CORRECT
C. 15 to 20 psi
D. 20 to 30 psi
Correct Answer: B
Rationale: Wound irrigation at 4 to 15 psi effectively removes debris and bacteria without
forcing solution into tissue or causing mechanical trauma to viable wound bed tissue.
Pressures below 4 psi are insufficient for cleansing contaminated wounds, while pressures
above 15 psi can drive bacteria deeper and damage granulation tissue. A 35-mL syringe with a
19-gauge needle or angiocatheter generates approximately 8 psi, which falls within the
recommended range.
Question 4 of 50
A 67-year-old patient with a diabetic foot ulcer has a wound photograph taken for
documentation. The nurse reviews the image and notes that the ruler is placed beside but not
in the same plane as the wound, and the flash creates a shadow across the wound bed. What
is the primary concern with this photograph?
A. The ruler placement does not affect measurement accuracy as long as it is visible
B. Shadowing improves contrast and makes tissue types easier to identify
C. The photograph should be taken without a ruler to avoid distracting from the wound
D. The ruler must be in the same plane as the wound, and shadowing obscures tissue detail ✓
CORRECT
Correct Answer: D
Rationale: Accurate wound photography requires placing the ruler in the same plane as the
wound surface to prevent parallax error that distorts measurements, and lighting must be
consistent without shadows to clearly visualize tissue types and wound characteristics.
Shadows obscure true color and tissue detail, while improper ruler placement leads to
, inaccurate size documentation. Standardized photography protocols ensure reliable
longitudinal comparison and legal documentation.
Question 5 of 50
A wound care nurse is evaluating a 71-year-old LTAC patient's sacral pressure injury. The
wound bed contains 100% bright red, beefy, granular tissue with small bumps that bleed easily
when touched. Which tissue type is predominant?
A. Granulation tissue ✓ CORRECT
B. Slough
C. Epithelial tissue
D. Eschar
Correct Answer: A
Rationale: Granulation tissue is characterized by its beefy red appearance, granular or bumpy
texture, and friability that causes easy bleeding upon contact, indicating healthy
vascularization and active wound healing. Slough is yellow, stringy, or moist necrotic tissue,
while eschar is black, brown, or tan leathery necrotic tissue. Epithelial tissue appears as pink,
translucent new skin migrating from wound edges or islands across the wound bed.
Question 6 of 50
A nurse is assessing a 58-year-old patient's surgical wound on postoperative day 5 and
observes thin, watery, pale red drainage saturating the dressing. How should this exudate be
documented?
A. Serous drainage
B. Serosanguineous drainage ✓ CORRECT
C. Sanguineous drainage
D. Purulent drainage
Correct Answer: B
Rationale: Serosanguineous drainage is thin, watery, and pale red or pink, containing both
serum and small amounts of blood, which is typical in the early inflammatory and
proliferative phases of healing. Serous drainage is clear and straw-colored, sanguineous
drainage is bright red and indicates active bleeding, and purulent drainage is thick, opaque,
and yellow, green, or tan indicating infection. Accurate exudate description guides dressing
selection and alerts clinicians to potential complications.
Question 7 of 50
