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WOUND CARE FINAL ACTUAL EXAM PREP
2026 ALL QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
ALREADY A GRADED WITH EXPERT
FEEDBACK| NEW AND REVISED
1. A patient with a Stage 3 pressure injury has a wound bed that is 50%
covered with yellow slough and 50% covered with red granulation
tissue. The nurse notes a moderate amount of purulent drainage and a
foul odor. Based on these findings, what is the priority nursing
intervention?
A. Apply a moisture-retentive dressing to promote autolytic debridement
B. Obtain a wound culture and initiate appropriate antimicrobial therapy
C. Debride the wound surgically to remove all non-viable tissue
D. Apply a hydrocolloid dressing to promote granulation
Correct Answer: B
Rationale: The presence of purulent drainage and foul odor indicates
a wound infection. The priority is to obtain a wound culture to identify
the causative organism and initiate appropriate antimicrobial therapy.
While debridement and appropriate dressing selection are important,
addressing the infection is the immediate priority.
2. A patient with a diabetic foot ulcer has a wound that is deep,
extending to the bone, with surrounding erythema and induration. The
patient reports increased pain and has a fever. What is the most
appropriate initial intervention?
A. Apply a topical antimicrobial dressing
B. Initiate systemic antibiotics and obtain imaging studies
C. Debride the wound and apply a moist dressing
D. Offload the foot with a total contact cast
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Correct Answer: B
Rationale: This patient has signs of a deep infection (pain, erythema,
induration, fever) that may involve bone (osteomyelitis). Systemic
antibiotics and imaging studies (X-ray, MRI) are indicated. Topical
therapy alone is insufficient for a deep infection, and offloading, while
important, is not the initial priority.
3. The nurse is assessing a patient's wound and notes that the wound
edges are rolled under (epibole). This finding indicates:
A. Normal wound healing
B. Wound infection
C. Wound healing is stalled
D. Excessive granulation tissue
Correct Answer: C
Rationale: Epibole (rolled wound edges) indicates that the wound
healing process is stalled because the epithelial cells cannot migrate
across the wound surface. It is a sign of a chronic, non-healing
wound. Intervention such as debridement or application of a moisture-
retentive dressing may be needed.
4. A patient with a venous leg ulcer has a wound with a moderate
amount of serous drainage, no signs of infection, and a wound bed that is
100% red granulation tissue. What is the most appropriate dressing for
this wound?
A. Alginate dressing
B. Hydrocolloid dressing
C. Foam dressing
D. Transparent film dressing
Correct Answer: C
Rationale: A foam dressing is appropriate for a wound with moderate
exudate and granulation tissue. Alginate dressings are for moderate to
heavy exudate, hydrocolloid dressings are for low to moderate exudate
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(but are less effective for heavily exudating wounds), and transparent
film dressings are for dry wounds or as a secondary dressing.
5. A patient with a pressure injury has a wound bed that is 100% covered
with black eschar. What is the most appropriate nursing action?
A. Apply a moisture-retentive dressing to promote autolytic debridement
B. Debride the eschar surgically or with sharp debridement
C. Apply a topical antibiotic ointment
D. Cover the wound with a dry sterile dressing
Correct Answer: B
Rationale: Black eschar is non-viable tissue that must be removed to
allow for wound healing. Sharp or surgical debridement is the most
effective method for removing eschar, especially if it is thick. Autolytic
debridement may be too slow, and topical antibiotics or dry dressings
do not address the non-viable tissue.
6. The nurse is assessing a patient's wound and notes that the wound bed
is covered with a thick, yellow, stringy material. This tissue is best
described as:
A. Slough
B. Eschar
C. Granulation tissue
D. Epithelial tissue
Correct Answer: A
Rationale: Slough is a yellow, stringy, fibrinous material that is
usually moist and can be easily removed. Eschar is black or brown and
is dry and hard. Granulation tissue is red, beefy, and granular.
Epithelial tissue is pink and shiny.
7. Which of the following is a sign of wound healing?
A. Increased pain
B. Decreased wound size
C. Purulent drainage
D. Foul odor
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Correct Answer: B
Rationale: A decrease in wound size is a sign of wound healing.
Increased pain, purulent drainage, and foul odor are signs of infection
or complications.
8. The nurse is assessing a patient's wound and notes that the peri-wound
skin is macerated. What is the most likely cause?
A. Excessive wound exudate
B. Wound infection
C. Allergic reaction to the dressing
D. Inadequate offloading
Correct Answer: A
Rationale: Maceration is caused by excessive moisture (exudate) that
softens the peri-wound skin. It is a sign that the current dressing is not
managing the exudate adequately. The nurse should select a dressing
with higher absorbency.
9. A patient with a Stage 4 pressure injury has a wound with
undermining at 3 o'clock of 3 cm. What is the most appropriate method
to measure this?
A. Measure the depth of the wound using a cotton-tipped applicator
B. Measure the width of the undermining by gently probing with a
cotton-tipped applicator
C. Measure the diameter of the wound with a ruler
D. Measure the circumference of the wound with a tape measure
Correct Answer: B
Rationale: Undermining is measured by gently inserting a cotton-
tipped applicator under the wound edge and measuring the distance
from the wound edge to the point where resistance is felt. This is
documented in centimeters and clock positions.
10. The TIME framework for wound assessment includes which of the
following components?
A. Tissue, Infection, Moisture, Edge
WOUND CARE FINAL ACTUAL EXAM PREP
2026 ALL QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
ALREADY A GRADED WITH EXPERT
FEEDBACK| NEW AND REVISED
1. A patient with a Stage 3 pressure injury has a wound bed that is 50%
covered with yellow slough and 50% covered with red granulation
tissue. The nurse notes a moderate amount of purulent drainage and a
foul odor. Based on these findings, what is the priority nursing
intervention?
A. Apply a moisture-retentive dressing to promote autolytic debridement
B. Obtain a wound culture and initiate appropriate antimicrobial therapy
C. Debride the wound surgically to remove all non-viable tissue
D. Apply a hydrocolloid dressing to promote granulation
Correct Answer: B
Rationale: The presence of purulent drainage and foul odor indicates
a wound infection. The priority is to obtain a wound culture to identify
the causative organism and initiate appropriate antimicrobial therapy.
While debridement and appropriate dressing selection are important,
addressing the infection is the immediate priority.
2. A patient with a diabetic foot ulcer has a wound that is deep,
extending to the bone, with surrounding erythema and induration. The
patient reports increased pain and has a fever. What is the most
appropriate initial intervention?
A. Apply a topical antimicrobial dressing
B. Initiate systemic antibiotics and obtain imaging studies
C. Debride the wound and apply a moist dressing
D. Offload the foot with a total contact cast
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Correct Answer: B
Rationale: This patient has signs of a deep infection (pain, erythema,
induration, fever) that may involve bone (osteomyelitis). Systemic
antibiotics and imaging studies (X-ray, MRI) are indicated. Topical
therapy alone is insufficient for a deep infection, and offloading, while
important, is not the initial priority.
3. The nurse is assessing a patient's wound and notes that the wound
edges are rolled under (epibole). This finding indicates:
A. Normal wound healing
B. Wound infection
C. Wound healing is stalled
D. Excessive granulation tissue
Correct Answer: C
Rationale: Epibole (rolled wound edges) indicates that the wound
healing process is stalled because the epithelial cells cannot migrate
across the wound surface. It is a sign of a chronic, non-healing
wound. Intervention such as debridement or application of a moisture-
retentive dressing may be needed.
4. A patient with a venous leg ulcer has a wound with a moderate
amount of serous drainage, no signs of infection, and a wound bed that is
100% red granulation tissue. What is the most appropriate dressing for
this wound?
A. Alginate dressing
B. Hydrocolloid dressing
C. Foam dressing
D. Transparent film dressing
Correct Answer: C
Rationale: A foam dressing is appropriate for a wound with moderate
exudate and granulation tissue. Alginate dressings are for moderate to
heavy exudate, hydrocolloid dressings are for low to moderate exudate
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(but are less effective for heavily exudating wounds), and transparent
film dressings are for dry wounds or as a secondary dressing.
5. A patient with a pressure injury has a wound bed that is 100% covered
with black eschar. What is the most appropriate nursing action?
A. Apply a moisture-retentive dressing to promote autolytic debridement
B. Debride the eschar surgically or with sharp debridement
C. Apply a topical antibiotic ointment
D. Cover the wound with a dry sterile dressing
Correct Answer: B
Rationale: Black eschar is non-viable tissue that must be removed to
allow for wound healing. Sharp or surgical debridement is the most
effective method for removing eschar, especially if it is thick. Autolytic
debridement may be too slow, and topical antibiotics or dry dressings
do not address the non-viable tissue.
6. The nurse is assessing a patient's wound and notes that the wound bed
is covered with a thick, yellow, stringy material. This tissue is best
described as:
A. Slough
B. Eschar
C. Granulation tissue
D. Epithelial tissue
Correct Answer: A
Rationale: Slough is a yellow, stringy, fibrinous material that is
usually moist and can be easily removed. Eschar is black or brown and
is dry and hard. Granulation tissue is red, beefy, and granular.
Epithelial tissue is pink and shiny.
7. Which of the following is a sign of wound healing?
A. Increased pain
B. Decreased wound size
C. Purulent drainage
D. Foul odor
, 4|Page
Correct Answer: B
Rationale: A decrease in wound size is a sign of wound healing.
Increased pain, purulent drainage, and foul odor are signs of infection
or complications.
8. The nurse is assessing a patient's wound and notes that the peri-wound
skin is macerated. What is the most likely cause?
A. Excessive wound exudate
B. Wound infection
C. Allergic reaction to the dressing
D. Inadequate offloading
Correct Answer: A
Rationale: Maceration is caused by excessive moisture (exudate) that
softens the peri-wound skin. It is a sign that the current dressing is not
managing the exudate adequately. The nurse should select a dressing
with higher absorbency.
9. A patient with a Stage 4 pressure injury has a wound with
undermining at 3 o'clock of 3 cm. What is the most appropriate method
to measure this?
A. Measure the depth of the wound using a cotton-tipped applicator
B. Measure the width of the undermining by gently probing with a
cotton-tipped applicator
C. Measure the diameter of the wound with a ruler
D. Measure the circumference of the wound with a tape measure
Correct Answer: B
Rationale: Undermining is measured by gently inserting a cotton-
tipped applicator under the wound edge and measuring the distance
from the wound edge to the point where resistance is felt. This is
documented in centimeters and clock positions.
10. The TIME framework for wound assessment includes which of the
following components?
A. Tissue, Infection, Moisture, Edge
