CWCN SAE: Questions And Verified Answers (Rated A+)
The Certified Wound Care Nurse (CWCN) is changing the dressing of an
elderly patient who has cognitive impairments. What is the MOST reliable way
to assess pain related to the wound? Right Ans - Observe the patient for
nonverbal behaviors such as grimacing
A patient presents with a chronic erythematous traumatic wound on the
anterior lower leg. Current care includes use of mupirocin (Bactroban) cream
and a four-layer compression wrap. Hypergranulation tissue is present in the
wound bed. Which modification should be made to this patient's treatment
program? Right Ans - Use foam dressing on the wound
Hypergranulation tissue Right Ans - excessive, soft, flaccid granulating
tissue that is raised above the level of the periwound tissue, preventing
proper epithelization, and may reflect excess moisture in the wound
Which of the following is MOST effective in protecting the surrounding skin of
a draining wound? Right Ans - Alcohol-free skin sealant
Under which circumstance is negative-pressure wound therapy (NPWT)
CONTRAINDICATED? Right Ans - Unexplored fistula
Contraindications for NPWT Right Ans - -Wound malignancy
-Untreated osteomyelitis
-Exposed blood vessels and organs
-Non-enteric, unexplored fistulas
Normal ABI Right Ans - 1-1.4
A new patient has an arterial ulcer from a fall 2 months ago that is increasing
in size. The patient shares that glucose levels each morning average 138. The
Certified Wound Care Nurse (CWCN) completes an ankle-brachial index and
calculates a score of 1.0. Pedal pulses are diminished. The wound is pale pink
with serous drainage and measures 3 cm. x 5 cm. x 0.3 cm. Which referral will
MOST likely increase wound healing success for this patient? Right Ans -
Vascular surgery
, Which wound and dressing combination is MOST appropriate to promote
autolytic debridement? Right Ans - A wound with slough and hydrocolloid
dressing
Autolytic debridement Right Ans - -Using the body's enzymes and WBCs to
debride the wound
-Requires secondary dressing covering (hydrocolloids, alginates, hydrogels,
and transparent films)
A Certified Wound Care Nurse (CWCN) is teaching a hospital orientation for
new nurse graduates and is discussing prevention of pressure injuries. One
nurse asks the CWCN about a patient who developed a deep tissue injury 3
days after admission even after going to extremes to relieve pressure. The
CWCN takes this opportunity to teach the importance of each assessment
related to deep tissue injury development. What information can the CWCN
provide to the nurse? Right Ans - Irreversible skin damage can occur
within a few hours but may not be visible for 2-5 days
A 45-year-old patient with paraplegia from a motor vehicle accident 3 years
ago has stage 3 pressure injuries to the greater trochanters bilaterally. The
patient was hospitalized secondary to appendicitis and is preparing for
discharge. Which outpatient referral should the Certified Wound Care Nurse
(CWCN) recommend FIRST at the visit? Right Ans - Physical therapy for
wheelchair evaluation
A 25-year-old patient is alert and oriented with paraplegia and intact skin.
When reviewing the Braden Scale, the charted score for Friction & Shear is
"Potential problem." The Certified Wound Care Nurse (CWCN) assesses the
patient to be working with physical therapy and witnesses sliding from
wheelchair to the bed with minimal assistance. Which factor makes the score
of "Potential Problem" a correct documentation for this patient? Right Ans
- Requiring minimal assistance
How often should a transparent film dressing be changed when covering a
dermal ulcer? Right Ans - Every 3-7 days or when fluid extends beyond
wound edges
The Certified Wound Care Nurse (CWCN) is changing the dressing of an
elderly patient who has cognitive impairments. What is the MOST reliable way
to assess pain related to the wound? Right Ans - Observe the patient for
nonverbal behaviors such as grimacing
A patient presents with a chronic erythematous traumatic wound on the
anterior lower leg. Current care includes use of mupirocin (Bactroban) cream
and a four-layer compression wrap. Hypergranulation tissue is present in the
wound bed. Which modification should be made to this patient's treatment
program? Right Ans - Use foam dressing on the wound
Hypergranulation tissue Right Ans - excessive, soft, flaccid granulating
tissue that is raised above the level of the periwound tissue, preventing
proper epithelization, and may reflect excess moisture in the wound
Which of the following is MOST effective in protecting the surrounding skin of
a draining wound? Right Ans - Alcohol-free skin sealant
Under which circumstance is negative-pressure wound therapy (NPWT)
CONTRAINDICATED? Right Ans - Unexplored fistula
Contraindications for NPWT Right Ans - -Wound malignancy
-Untreated osteomyelitis
-Exposed blood vessels and organs
-Non-enteric, unexplored fistulas
Normal ABI Right Ans - 1-1.4
A new patient has an arterial ulcer from a fall 2 months ago that is increasing
in size. The patient shares that glucose levels each morning average 138. The
Certified Wound Care Nurse (CWCN) completes an ankle-brachial index and
calculates a score of 1.0. Pedal pulses are diminished. The wound is pale pink
with serous drainage and measures 3 cm. x 5 cm. x 0.3 cm. Which referral will
MOST likely increase wound healing success for this patient? Right Ans -
Vascular surgery
, Which wound and dressing combination is MOST appropriate to promote
autolytic debridement? Right Ans - A wound with slough and hydrocolloid
dressing
Autolytic debridement Right Ans - -Using the body's enzymes and WBCs to
debride the wound
-Requires secondary dressing covering (hydrocolloids, alginates, hydrogels,
and transparent films)
A Certified Wound Care Nurse (CWCN) is teaching a hospital orientation for
new nurse graduates and is discussing prevention of pressure injuries. One
nurse asks the CWCN about a patient who developed a deep tissue injury 3
days after admission even after going to extremes to relieve pressure. The
CWCN takes this opportunity to teach the importance of each assessment
related to deep tissue injury development. What information can the CWCN
provide to the nurse? Right Ans - Irreversible skin damage can occur
within a few hours but may not be visible for 2-5 days
A 45-year-old patient with paraplegia from a motor vehicle accident 3 years
ago has stage 3 pressure injuries to the greater trochanters bilaterally. The
patient was hospitalized secondary to appendicitis and is preparing for
discharge. Which outpatient referral should the Certified Wound Care Nurse
(CWCN) recommend FIRST at the visit? Right Ans - Physical therapy for
wheelchair evaluation
A 25-year-old patient is alert and oriented with paraplegia and intact skin.
When reviewing the Braden Scale, the charted score for Friction & Shear is
"Potential problem." The Certified Wound Care Nurse (CWCN) assesses the
patient to be working with physical therapy and witnesses sliding from
wheelchair to the bed with minimal assistance. Which factor makes the score
of "Potential Problem" a correct documentation for this patient? Right Ans
- Requiring minimal assistance
How often should a transparent film dressing be changed when covering a
dermal ulcer? Right Ans - Every 3-7 days or when fluid extends beyond
wound edges
