NAWCO WCC Exam Questions

Correct answer: Wagner grade 3 or higher 

HBOT may be considered for the treatment of patients with limb-threatening diabetic and vascular insufficiency wounds of the lower extremity. To meet the Centers for Medicare and Medicaid Services (CMS) criteria, the lower extremity diabetic wound must be Wagner grade 3 or higher and not responsive to standard wound care, including the assessment and correction of vascular insufficiency, maximization of nutritional status, optimization of glycemic control, debridement of nonvital tissue, and maintenance of moist wound healing with the use of topical dressings. 

While other classification systems are recommended for use with diabetic foot ulcers, for reimbursement purposes, the National Coverage Determination (NCD) continues to insist that the Wagner Classification System must be used. 

Correct answer: Grade 2B

The University of Texas system utilizes a matrix structure with four grades of wound depth and four associated stages to specify ischemia, infection, both ischemia and infection, or neither. The UTSA classification system has been judged superior to the original Wagner system as a predictor of patient outcomes. 

• grade 0: no open lesions, may have deformity
• grade 1: superficial wound not involving the tendon, capsule, or bone
• grade 2: wound penetrating to tendon or capsule
• grade 3: wound penetrating to bone or joint

Following each grade are four stages. Stage A is without infection or ischemia (neither), stage B is with infection, stage C is with ischemia, and stage D is with infection and ischemia (both).

Therefore, a diabetic foot ulcer/wound that is penetrating to the tendon with an infection will receive UTSA grade 2B. 

Correct answer: Systemic broad-spectrum antibiotic therapy 

Systemic antibiotics are contraindicated in this scenario because there are no signs of infection in the wound. Systemic antibiotics are generally reserved for treating clinically infected wounds and preventing the spread of infection in specific cases. Overuse of antibiotics can lead to resistance, unnecessary side effects, and additional costs. Since the patient's wound does not exhibit signs of infection, systemic antibiotics would not be appropriate or beneficial.

Alginate dressings are highly absorbent and thus appropriate for wounds with moderate to high levels of exudate. These dressings help maintain a moist wound environment conducive to healing and are particularly useful for managing exudate from venous leg ulcers. Compression therapy is indicated in the case of a venous leg ulcer, especially when coupled with chronic venous insufficiency. It helps reduce edema and improve venous return, which are critical aspects of managing and healing venous leg ulcers. Hydrocolloid dressings are suitable for wounds with moderate exudate like this one. They help maintain a moist environment, which promotes wound healing, and can also help manage exudate without drying out the wound bed.

Correct answer: Surgical sharp 

The goal of debridement is to restore the wound base and functional extracellular matrix (ECM) proteins. The objectives are to get rid of necrotic tissue, prevent infection, and correct abnormal wound repair. It has become an essential principle in the treatment of acute and chronic wounds. 

Debridement methods are classified as either selective (only necrotic tissue is removed) or nonselective (viable tissue is removed along with the nonviable tissue). More specifically, debridement is classified by the actual mechanism of action: autolysis, chemical (using enzymes or silver nitrate), mechanical (wet-to-dry gauze, ultrasonic mist, and hydrotherapy), biologic (biosurgical), or sharp (conservative or surgical). 

Surgical sharp debridement is a nonselective method involving the use of a sterile scalpel, forceps, curette, scissors, or another sharp instrument to remove necrotic tissue (viable tissue may also be removed during this process as necessary). It is the most rapid means of debridement and is done surgically. 

Biosurgical (maggots), autolysis (lysis of necrotic tissue by the body's white blood cells), and enzymatic (topical application of exogenous enzyme collagenase) are all selective methods of debridement. 

Correct answer: Alginates 

Alginates are the calcium or calcium/sodium salts of alginic acid and are composed of mannuronic and guluronic acids obtained from seaweed. When applied to a wound, sodium ions in the wound exchange for the calcium ions in the dressing, absorbing serous fluid or exudate and forming a nonadhesive, nonocclusive hydrophilic gel that conforms to the shape of the wound. Since calcium acts as a clotting factor (factor IV), this mechanism enables some alginates to act as a hemostat. 

Alginates are indicated for moderately to highly exudative full-thickness wound cavities (such as stage III or IV pressure ulcers) and may also be considered for infected pressure ulcers, as long as appropriate concurrent treatment for infection is implemented. 

Correct answer: Calcium metabolism 

Vitamin D plays a crucial role in regulating calcium levels, maintaining bone health, promoting cell differentiation, and supporting a healthy immune system. While the body can produce vitamin D when exposed to sunlight, many individuals do not receive adequate sun exposure, leading to deficiency. Additionally, vitamin D can be obtained from fortified milk, breakfast cereals, select fatty fish like salmon and sardines, and through supplementation.

Vitamin C, protein, iron, and zinc are all involved in the synthesis and formation of collagen. Vitamin K is essential for proper blood clotting, thus aiding in effective wound healing. Vitamin A contributes to epithelialization and angiogenesis processes.

Correct answer: Begin Negative Pressure Wound Therapy (NPWT) 

NPWT has been extensively studied and shown to be effective in promoting wound healing by enhancing tissue perfusion, removing excess exudate, reducing bacterial load, and promoting the formation of granulation tissue. It is considered a standard treatment modality for managing surgical wound infections and is supported by research studies and clinical guidelines.

Administering oral antibiotics without assessing the wound culture is not aligned with evidence-based practice. Proper wound culture and sensitivity testing are essential for selecting the appropriate antibiotic therapy tailored to the specific infecting microorganisms. Empirical antibiotic treatment without culture guidance can lead to inappropriate antibiotic use, antibiotic resistance, and treatment failure. Wound debridement should be performed judiciously, taking into account factors such as the patient's comorbidities, wound characteristics, and overall clinical condition. Failure to consider these factors may increase the risk of complications and delay wound healing. Occlusive dressings to keep the wound moist may not be appropriate for surgical wound infections. While maintaining a moist wound environment is generally beneficial for wound healing, occlusive dressings may trap bacteria and exacerbate infection in the case of surgical wound infections. Proper wound assessment and management, including debridement and infection control measures, are paramount in such cases.

Correct answer: Regular repositioning and a pressure-redistributing support surface

Regular repositioning and the use of a pressure-redistributing support surface are essential interventions for treating pressure ulcers. The primary cause of pressure ulcers is prolonged pressure on the skin and underlying tissues, reducing blood flow and leading to tissue damage. Regularly repositioning the patient and using specialized support surfaces will minimize pressure and shear forces, allowing proper blood flow to the area, promoting healing, and reducing further tissue injury. This approach is widely supported by evidence-based guidelines and is considered a standard of care.

Hydrocolloid dressings can be beneficial for managing wound exudate and maintaining a moist environment conducive to healing. However, they are not as effective when used alone for pressure ulcers, especially those in Stage 3, which involves deeper tissue damage. The underlying pressure problem must still be addressed through offloading to facilitate healing. While iodine has antiseptic properties, daily iodine treatment is not necessary for managing all pressure ulcers and can actually hinder healing. Iodine can damage new tissue and delay wound healing if used excessively. Managing pressure, rather than overusing antiseptics, is more effective and evidence based. Local antiseptic irrigation can be helpful if there's an active infection or excessive bioburden, but it is not routinely recommended for all Stage 3 pressure ulcers. Frequent irrigation with antiseptics can irritate the wound bed, causing additional inflammation and delaying healing. The primary focus should be on relieving the mechanical stress on the wound through pressure redistribution.

Correct answer: A verbally communicative adult complaining of post-surgical wound pain

The Numeric Pain Rating Scale asks patients to rate their pain on a scale from 0 (no pain) to 10 (worst possible pain). It is ideal for adults who can understand and communicate their pain levels effectively. Toddlers, sedated patients, and nonverbal adults with dementia cannot effectively use or understand the Numeric Pain Rating Scale due to communication barriers or cognitive limitations and should be given a different pain assessment tool to utilize.

Correct answer: An occlusive dressing 

Autolytic debridement uses the body's intrinsic debriding mechanisms to remove nonviable or necrotic tissue; the tissue is liquefied using the body's natural enzymes (phagocytic cells, proteolytic enzymes). This process is accomplished by keeping the wound moist with occlusive or semi-occlusive dressings, and it only works if the wound stays moist. The dressing should be undisturbed (as this is a slow, painless process) for a reasonable time, typically 24 to 72 hours. 

Biosurgery, or maggot debridement therapy (MDT) is the application of uninfected maggots to the wound to remove the nonviable tissue.

Pulsatile lavage is a form of hydrotherapy.

The use of a scalpel or other sharp instrument to remove nonviable tissue is referred to as sharp debridement. 

Correct answer: Stage II

Stage I and II pressure ulcers would be appropriately diagnosed as "impaired skin integrity," as stage I still has intact skin with non-blanchable erythema, and stage II involves only partial thickness damage or serous fluid blistering. 

Stage III and IV pressure ulcers, as well as unstageable pressure injuries, involve full-thickness skin and tissue loss. They are more severe than just skin integrity impairment. 

Correct answer: Apply a compression bandage

Applying a compression bandage is the correct action for managing a venous leg ulcer in accordance with a standardized protocol. Compression therapy addresses the underlying cause of venous ulcers by improving venous return, reducing edema, and decreasing venous pressure, which contributes to ulcer formation and hinders healing. Addressing the root cause with compression therapy is critical to managing venous ulcers and aligns with standardized wound care protocols.

A non-adherent dressing might help prevent trauma to the wound bed, but it does not address the underlying venous insufficiency. Compression therapy is necessary to manage the ulcer's cause and prevent its worsening. While a referral might be necessary later, particularly for long-term management or surgical options, immediate management of the wound through compression therapy is essential to promote healing and align with standardized protocols. Cleaning the wound and applying an antimicrobial dressing can help manage potential infection and prepare the wound bed, but it does not directly address the underlying cause of the venous ulcer, which is poor venous return and edema. 

Correct answer: Ingestion, destruction, and digestion of cellular particulate matter 

Phagocytosis is the ingestion of bacteria or other material by phagocytes (white blood cells that engulf and destroy pathogens). Neutrophils are the most common type of phagocyte, making up 50% to 70% of the white blood cells in the body. 

Chemotaxis is the attraction of a cell in response to a chemical signal.

Angiogenesis or neovascularization is the development of new blood vessels in injured tissues.

Galvanotaxis is the attraction of a cell in response to an electrical signal. 

Correct answer: Certifications enhance staff competence and patient outcomes

Certifications provide structured, comprehensive education that equips staff with advanced knowledge and skills. This leads to better clinical decision-making, improved treatment strategies, and more effective wound care management, resulting in enhanced patient outcomes. The learning process ensures that healthcare professionals remain current with best practices and new research.

While certifications may enhance professional prestige or reputation, this should not be the primary reason for obtaining them. While some healthcare facilities offer bonuses or higher pay for certifications, the primary incentive should be professional development and the ability to provide higher-quality care. Certifications can improve efficiency through better treatment approaches, but they don't necessarily reduce the total time spent on patient care. Instead, they enable more effective and appropriate treatment strategies, improving healing time and patient satisfaction without necessarily focusing on speed.

Correct answer: Clotting 

There are four primary phases of wound healing:

1. Hemostasis (vascular): platelets seal the bleeding vessels, and thrombin is produced to stimulate the clotting mechanism.
2. Inflammatory: inflammation occurs (erythema and edema along with pain) as the blood vessels release plasma and neutrophils to begin phagocytosis to remove debris and prevent infection.
3. Proliferative/granulation (fibroblastic): fibroblasts produce collagen to provide support, and granulation tissue starts to form.
4. Maturation (differentiation, remodeling, or plateau): fibroblasts leave the wound, and collagen tightens to reduce scarring.

Correct answer: Decreased time for epidermal regeneration 

As a person grows older, the time taken for epidermal regeneration lengthens, and the skin sustains more damage from sun exposure. Various changes occur in the skin, including reductions in dermal thickness, fatty layers, collagen and elastin levels, size of rete ridges, sensation, metabolism, sweat gland activity, subcutaneous tissue, and circulation.

Correct answer: Superficial-thickness burn

Blanching redness without blisters indicates a superficial-thickness burn (first-degree). With first-degree burns, the epidermis remains intact and without blisters. The skin is erythematous and blanches with pressure. 

Correct answer: Grade 3

The Wagner Ulcer Grade Classification system is used to establish the presence of depth and infection in a wound, and it is commonly used as an assessment instrument in the evaluation of diabetic foot ulcers. There are six grades, progressing from 0 to 5 in the order of severity of breakdown in the diabetic, neuropathic foot. 

Grade 3 is a deep, infected wound with an abscess or tendon or bone involvement (osteomyelitis). 

Correct answer: Include high-quality images and graphics for visual interest

High-quality images and graphics help convey complex information visually, making it easier for the audience to understand and retain. Visual aids enhance engagement by presenting information in a memorable way and breaking down complicated concepts into digestible chunks. They appeal to multiple learning styles, reinforcing textual explanations and improving overall comprehension.

While medical jargon may enhance credibility among professionals, it can confuse and alienate non-professionals, reducing their understanding. Simpler language that remains accurate is essential for broad engagement. Text-only content may not accommodate various learning preferences and often lacks the depth or impact of multimedia presentations. Visual, auditory, and interactive elements generally improve engagement and comprehension. People have varied learning preferences, and effective educational materials should incorporate different styles to reach a broader audience. Using only one style may exclude individuals who learn better in other ways.

Correct answer: Necrotic tissue

Slough is an avascular (nonviable) tissue (necrotic/devitalized) that is typically moist and soft. It may be tan, yellow, green, or white, and firmly or loosely adherent to the wound bed. It has a moderate to high water content, and is made up of fibrin debris. 

Granulation tissue is moist tissue that is pink or red; it is composed of new blood vessels, connective tissue, fibroblasts, and inflammatory cells that fill an open wound when it starts to heal. It has a granular surface that is berry-like or cobblestone.