FLORIDA BOARD OF NURSING CERTIFIED
WOUND OSTOMY NURSE EXAM WITH
ACTUAL QUESTIONS AND VERIFIED
ANSWERS, PLUS EXPLAINED
RATIONALES/EXPERT VERIFIED FOR
GUARANTEED 100% PASS 2026/LATEST
UPDATE/INSTANT DOWNLOAD PDF
1. A 72-year-old patient who is immobile after a stroke has
nonblanchable erythema over the sacrum. The skin is intact, and the
area feels warmer and firmer than the surrounding tissue. Which
classification is most appropriate?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue pressure injury
Answer: A. Stage 1 pressure injury
Rationale: Stage 1 pressure injury is characterized by intact skin with
localized nonblanchable erythema. Changes in temperature, tissue
consistency, and sensation may accompany the discoloration. Stage 2
involves partial-thickness skin loss with exposed dermis, while stage 3
involves full-thickness skin loss. Deep tissue pressure injury typically
presents with persistent deep red, maroon, or purple discoloration or a
blood-filled blister suggestive of underlying tissue damage.
2. A patient with a sacral wound has full-thickness skin loss.
Adipose tissue and granulation tissue are visible, but there is no
exposed fascia, muscle, tendon, cartilage, or bone. Which stage
should the wound nurse document?
1
,A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C. Stage 3
Rationale: Stage 3 pressure injury involves full-thickness skin loss in
which adipose tissue and granulation tissue may be visible. Epibole,
undermining, and slough or eschar may also occur. If deeper
structures such as fascia, muscle, tendon, cartilage, or bone are
exposed or directly palpable, the injury is stage 4.
3. During assessment of a heel wound, the nurse observes intact skin
with persistent maroon discoloration and a blood-filled blister. The
patient reports severe tenderness. Which finding is most consistent
with a deep tissue pressure injury?
A. Partial-thickness epidermal loss
B. Deep tissue pressure injury
C. Stage 3 pressure injury
D. Moisture-associated skin damage
Answer: B. Deep tissue pressure injury
Rationale: Deep tissue pressure injury results from damage to
underlying soft tissue caused by pressure and/or shear. Persistent deep
red, maroon, or purple discoloration, a blood-filled blister,
temperature changes, and pain may occur despite intact or minimally
disrupted skin. The visible surface may underestimate the extent of
underlying tissue damage.
4. A patient with a stage 4 sacral pressure injury has exposed bone.
Which complication requires particularly careful monitoring?
2
,A. Osteomyelitis
B. Contact dermatitis
C. Hyperkeratosis
D. Seborrheic dermatitis
Answer: A. Osteomyelitis
Rationale: A stage 4 pressure injury with exposed or palpable bone
creates substantial risk for infection of the underlying bone, or
osteomyelitis. Clinical assessment may include increasing drainage,
malodor, deterioration of the wound, exposed bone, systemic
manifestations, and other findings. Further diagnostic evaluation may
be required when osteomyelitis is suspected.
5. A patient has a wound on the lateral ankle caused by arterial
insufficiency. Which assessment finding would most strongly
support an arterial etiology?
A. Warm skin with edema and hemosiderin staining
B. Irregular shallow wound with heavy exudate
C. Punched-out wound with a pale or necrotic base
D. Wound surrounding a moist macerated area caused by incontinence
Answer: C. Punched-out wound with a pale or necrotic base
Rationale: Arterial ulcers commonly occur over distal pressure points
such as the toes, feet, malleoli, or heels and may have a sharply
demarcated or punched-out appearance. The wound may have a pale,
gray, or necrotic base and may be associated with diminished pulses,
cool skin, delayed capillary refill, and ischemic pain.
6. A patient with chronic venous insufficiency has a shallow ulcer
near the medial malleolus. Which additional finding is most
characteristic?
3
, A. Hairless shiny skin with absent pulses
B. Dependent rubor and severe ischemic pain
C. Edema, hemosiderin deposition, and gaiter-area ulceration
D. Black eschar over the distal toes with cool skin
Answer: C. Edema, hemosiderin deposition, and gaiter-area
ulceration
Rationale: Venous leg ulcers commonly occur in the gaiter region,
particularly around the medial malleolus. Chronic venous
hypertension can produce edema, hemosiderin deposition, stasis
dermatitis, lipodermatosclerosis, and other characteristic changes.
Arterial disease is more commonly associated with cool skin,
diminished pulses, and distal ischemic wounds.
7. Before applying compression therapy to a patient with a lower-
extremity venous ulcer, which assessment is particularly important?
A. Serum sodium level
B. Ankle-brachial index or other arterial perfusion assessment
C. Urine specific gravity
D. Pupillary response
Answer: B. Ankle-brachial index or other arterial perfusion
assessment
Rationale: Compression increases external pressure on the limb and
can be harmful when significant arterial insufficiency is present.
Arterial perfusion should therefore be assessed before compression
therapy. The ABI is commonly used as part of the vascular
assessment, although clinicians should recognize situations in which
arterial calcification may make ABI results unreliable and alternative
vascular studies may be necessary.
4
WOUND OSTOMY NURSE EXAM WITH
ACTUAL QUESTIONS AND VERIFIED
ANSWERS, PLUS EXPLAINED
RATIONALES/EXPERT VERIFIED FOR
GUARANTEED 100% PASS 2026/LATEST
UPDATE/INSTANT DOWNLOAD PDF
1. A 72-year-old patient who is immobile after a stroke has
nonblanchable erythema over the sacrum. The skin is intact, and the
area feels warmer and firmer than the surrounding tissue. Which
classification is most appropriate?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue pressure injury
Answer: A. Stage 1 pressure injury
Rationale: Stage 1 pressure injury is characterized by intact skin with
localized nonblanchable erythema. Changes in temperature, tissue
consistency, and sensation may accompany the discoloration. Stage 2
involves partial-thickness skin loss with exposed dermis, while stage 3
involves full-thickness skin loss. Deep tissue pressure injury typically
presents with persistent deep red, maroon, or purple discoloration or a
blood-filled blister suggestive of underlying tissue damage.
2. A patient with a sacral wound has full-thickness skin loss.
Adipose tissue and granulation tissue are visible, but there is no
exposed fascia, muscle, tendon, cartilage, or bone. Which stage
should the wound nurse document?
1
,A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C. Stage 3
Rationale: Stage 3 pressure injury involves full-thickness skin loss in
which adipose tissue and granulation tissue may be visible. Epibole,
undermining, and slough or eschar may also occur. If deeper
structures such as fascia, muscle, tendon, cartilage, or bone are
exposed or directly palpable, the injury is stage 4.
3. During assessment of a heel wound, the nurse observes intact skin
with persistent maroon discoloration and a blood-filled blister. The
patient reports severe tenderness. Which finding is most consistent
with a deep tissue pressure injury?
A. Partial-thickness epidermal loss
B. Deep tissue pressure injury
C. Stage 3 pressure injury
D. Moisture-associated skin damage
Answer: B. Deep tissue pressure injury
Rationale: Deep tissue pressure injury results from damage to
underlying soft tissue caused by pressure and/or shear. Persistent deep
red, maroon, or purple discoloration, a blood-filled blister,
temperature changes, and pain may occur despite intact or minimally
disrupted skin. The visible surface may underestimate the extent of
underlying tissue damage.
4. A patient with a stage 4 sacral pressure injury has exposed bone.
Which complication requires particularly careful monitoring?
2
,A. Osteomyelitis
B. Contact dermatitis
C. Hyperkeratosis
D. Seborrheic dermatitis
Answer: A. Osteomyelitis
Rationale: A stage 4 pressure injury with exposed or palpable bone
creates substantial risk for infection of the underlying bone, or
osteomyelitis. Clinical assessment may include increasing drainage,
malodor, deterioration of the wound, exposed bone, systemic
manifestations, and other findings. Further diagnostic evaluation may
be required when osteomyelitis is suspected.
5. A patient has a wound on the lateral ankle caused by arterial
insufficiency. Which assessment finding would most strongly
support an arterial etiology?
A. Warm skin with edema and hemosiderin staining
B. Irregular shallow wound with heavy exudate
C. Punched-out wound with a pale or necrotic base
D. Wound surrounding a moist macerated area caused by incontinence
Answer: C. Punched-out wound with a pale or necrotic base
Rationale: Arterial ulcers commonly occur over distal pressure points
such as the toes, feet, malleoli, or heels and may have a sharply
demarcated or punched-out appearance. The wound may have a pale,
gray, or necrotic base and may be associated with diminished pulses,
cool skin, delayed capillary refill, and ischemic pain.
6. A patient with chronic venous insufficiency has a shallow ulcer
near the medial malleolus. Which additional finding is most
characteristic?
3
, A. Hairless shiny skin with absent pulses
B. Dependent rubor and severe ischemic pain
C. Edema, hemosiderin deposition, and gaiter-area ulceration
D. Black eschar over the distal toes with cool skin
Answer: C. Edema, hemosiderin deposition, and gaiter-area
ulceration
Rationale: Venous leg ulcers commonly occur in the gaiter region,
particularly around the medial malleolus. Chronic venous
hypertension can produce edema, hemosiderin deposition, stasis
dermatitis, lipodermatosclerosis, and other characteristic changes.
Arterial disease is more commonly associated with cool skin,
diminished pulses, and distal ischemic wounds.
7. Before applying compression therapy to a patient with a lower-
extremity venous ulcer, which assessment is particularly important?
A. Serum sodium level
B. Ankle-brachial index or other arterial perfusion assessment
C. Urine specific gravity
D. Pupillary response
Answer: B. Ankle-brachial index or other arterial perfusion
assessment
Rationale: Compression increases external pressure on the limb and
can be harmful when significant arterial insufficiency is present.
Arterial perfusion should therefore be assessed before compression
therapy. The ABI is commonly used as part of the vascular
assessment, although clinicians should recognize situations in which
arterial calcification may make ABI results unreliable and alternative
vascular studies may be necessary.
4
