Wound Care Competency Exam — Code:
NUR-WOUND-COMP | 100-Question
Advanced Practice Exam 2026 |
Questions & Answers with Detailed
Rationales | Complete Exam Prep &
Study Guide
1. A patient with a sacral wound has full-thickness skin loss with adipose tissue
visible. Slough partially obscures the wound bed, but there is no exposed fascia,
muscle, tendon, cartilage, or bone. How should the wound be staged?
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 wound is not unstageable unless the extent of tissue damage cannot be
determined because the wound bed is completely obscured.
,2. A heel injury appears as an intact area of persistent maroon discoloration
that does not blanch with pressure. Which classification is most appropriate?
A. Stage 1 pressure injury
B. Deep tissue pressure injury
C. Stage 2 pressure injury
D. Unstageable pressure injury
Answer: B. Deep tissue pressure injury
Rationale: Persistent nonblanchable deep red, maroon, or purple discoloration
of intact or nonintact skin suggests damage to deeper tissues and is
characteristic of a deep tissue pressure injury.
3. During wound assessment, a nurse documents a wound measuring 5 cm × 3
cm × 0.8 cm with a 2-cm tunnel at the 6-o'clock position. Which documentation
is most complete?
A. "Large deep wound with tunneling"
B. "5 × 3 × 0.8 cm wound with tunneling"
C. "5 cm length × 3 cm width × 0.8 cm depth; 2-cm tunnel at 6 o'clock"
D. "Sacral wound approximately 15 cm²"
Answer: C. "5 cm length × 3 cm width × 0.8 cm depth; 2-cm tunnel at 6 o'clock"
Rationale: Comprehensive wound documentation should include measurements,
depth, and the location and extent of tunneling or undermining. Clock-face
descriptions improve reproducibility between assessments.
4. A patient with a venous leg ulcer has moderate edema, hemosiderin staining,
and a shallow irregular wound near the medial malleolus. Which intervention
most directly addresses the underlying pathophysiology?
,A. Strict bed rest
B. Compression therapy after arterial status is assessed
C. High-dose systemic corticosteroids
D. Routine dry gauze packing
Answer: B. Compression therapy after arterial status is assessed
Rationale: Venous hypertension is a major contributor to venous leg ulcers.
Compression reduces venous pooling and edema, but arterial circulation should
be assessed before compression to reduce the risk of ischemic complications.
5. Which wound finding is most characteristic of an arterial ulcer?
A. Medial ankle location with heavy exudate
B. Irregular shallow wound with surrounding edema
C. Distal foot or toe wound with punched-out appearance
D. Wound associated with brown hemosiderin staining
Answer: C. Distal foot or toe wound with punched-out appearance
Rationale: Arterial ulcers commonly occur on distal areas such as toes, feet, or
pressure points and often have sharply demarcated, punched-out borders. They
may be painful and associated with diminished perfusion.
6. A patient with a diabetic foot ulcer has a wound that probes to bone. Which
complication should the nurse recognize as particularly concerning?
A. Cellulitis only
B. Osteomyelitis
C. Contact dermatitis
D. Venous insufficiency
Answer: B. Osteomyelitis
, Rationale: A diabetic foot ulcer that probes to bone raises significant concern for
underlying osteomyelitis and requires prompt clinical evaluation.
7. Which characteristic most strongly suggests wound infection rather than
normal inflammation?
A. Mild erythema immediately after debridement
B. Small amount of serous drainage
C. Increasing pain, purulent drainage, and spreading erythema
D. Formation of healthy granulation tissue
Answer: C. Increasing pain, purulent drainage, and spreading erythema
Rationale: Increasing pain, purulent drainage, spreading erythema, warmth,
edema, systemic symptoms, or deterioration of the wound can indicate
infection. Healthy granulation tissue and limited serous drainage are generally
expected during healing.
8. A chronic wound has a thick layer of necrotic tissue that completely obscures
the wound base. Which pressure-injury classification is appropriate?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: D. Unstageable
Rationale: When slough or eschar completely obscures the extent of tissue
damage, the wound cannot be accurately staged until the obscuring tissue is
removed or the depth can otherwise be determined.
NUR-WOUND-COMP | 100-Question
Advanced Practice Exam 2026 |
Questions & Answers with Detailed
Rationales | Complete Exam Prep &
Study Guide
1. A patient with a sacral wound has full-thickness skin loss with adipose tissue
visible. Slough partially obscures the wound bed, but there is no exposed fascia,
muscle, tendon, cartilage, or bone. How should the wound be staged?
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 wound is not unstageable unless the extent of tissue damage cannot be
determined because the wound bed is completely obscured.
,2. A heel injury appears as an intact area of persistent maroon discoloration
that does not blanch with pressure. Which classification is most appropriate?
A. Stage 1 pressure injury
B. Deep tissue pressure injury
C. Stage 2 pressure injury
D. Unstageable pressure injury
Answer: B. Deep tissue pressure injury
Rationale: Persistent nonblanchable deep red, maroon, or purple discoloration
of intact or nonintact skin suggests damage to deeper tissues and is
characteristic of a deep tissue pressure injury.
3. During wound assessment, a nurse documents a wound measuring 5 cm × 3
cm × 0.8 cm with a 2-cm tunnel at the 6-o'clock position. Which documentation
is most complete?
A. "Large deep wound with tunneling"
B. "5 × 3 × 0.8 cm wound with tunneling"
C. "5 cm length × 3 cm width × 0.8 cm depth; 2-cm tunnel at 6 o'clock"
D. "Sacral wound approximately 15 cm²"
Answer: C. "5 cm length × 3 cm width × 0.8 cm depth; 2-cm tunnel at 6 o'clock"
Rationale: Comprehensive wound documentation should include measurements,
depth, and the location and extent of tunneling or undermining. Clock-face
descriptions improve reproducibility between assessments.
4. A patient with a venous leg ulcer has moderate edema, hemosiderin staining,
and a shallow irregular wound near the medial malleolus. Which intervention
most directly addresses the underlying pathophysiology?
,A. Strict bed rest
B. Compression therapy after arterial status is assessed
C. High-dose systemic corticosteroids
D. Routine dry gauze packing
Answer: B. Compression therapy after arterial status is assessed
Rationale: Venous hypertension is a major contributor to venous leg ulcers.
Compression reduces venous pooling and edema, but arterial circulation should
be assessed before compression to reduce the risk of ischemic complications.
5. Which wound finding is most characteristic of an arterial ulcer?
A. Medial ankle location with heavy exudate
B. Irregular shallow wound with surrounding edema
C. Distal foot or toe wound with punched-out appearance
D. Wound associated with brown hemosiderin staining
Answer: C. Distal foot or toe wound with punched-out appearance
Rationale: Arterial ulcers commonly occur on distal areas such as toes, feet, or
pressure points and often have sharply demarcated, punched-out borders. They
may be painful and associated with diminished perfusion.
6. A patient with a diabetic foot ulcer has a wound that probes to bone. Which
complication should the nurse recognize as particularly concerning?
A. Cellulitis only
B. Osteomyelitis
C. Contact dermatitis
D. Venous insufficiency
Answer: B. Osteomyelitis
, Rationale: A diabetic foot ulcer that probes to bone raises significant concern for
underlying osteomyelitis and requires prompt clinical evaluation.
7. Which characteristic most strongly suggests wound infection rather than
normal inflammation?
A. Mild erythema immediately after debridement
B. Small amount of serous drainage
C. Increasing pain, purulent drainage, and spreading erythema
D. Formation of healthy granulation tissue
Answer: C. Increasing pain, purulent drainage, and spreading erythema
Rationale: Increasing pain, purulent drainage, spreading erythema, warmth,
edema, systemic symptoms, or deterioration of the wound can indicate
infection. Healthy granulation tissue and limited serous drainage are generally
expected during healing.
8. A chronic wound has a thick layer of necrotic tissue that completely obscures
the wound base. Which pressure-injury classification is appropriate?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: D. Unstageable
Rationale: When slough or eschar completely obscures the extent of tissue
damage, the wound cannot be accurately staged until the obscuring tissue is
removed or the depth can otherwise be determined.
