NAWCO WCC Exam Questions

Correct answer: Justice 

The principle of justice ensures that all patients receive equitable treatment regardless of cultural background, which is particularly important in culturally sensitive wound care. Justice requires that medical decisions do not favor or disadvantage any group, ensuring fairness and equality in care delivery, including considering cultural beliefs and practices.

Beneficence promotes doing good for the patient but does not specifically address the need for fair and equal treatment across different cultural backgrounds. While beneficence is important in wound care, it does not explicitly ensure cultural sensitivity. Non-maleficence focuses on avoiding harm, which is crucial in medical practice. However, it does not explicitly address fairness of treatment across cultural backgrounds. Justice ensures that cultural considerations are taken into account to avoid discrimination or unequal treatment. Autonomy emphasizes the patient's right to make their own decisions regarding their care, including considerations of cultural beliefs. However, justice ensures that all patients, regardless of cultural background, receive equal and fair treatment, making it more directly relevant to the question.

Correct answer: Transparent film dressing 

A transparent film dressing is indicated for a clean, dry superficial abrasion as it provides protection, allows for wound visualization, and helps maintain a moist wound environment conducive to healing.

Dry gauze dressings are commonly used for wounds with minimal exudate. However, they do not create a moist wound environment, which may not be optimal for promoting healing in a superficial abrasion. Additionally, dry gauze dressings may adhere to the wound bed when removed, causing trauma and pain to the patient. Honey-based dressings have antimicrobial properties and promote wound healing, making them suitable for wounds with signs of infection or those at risk of infection. However, in this scenario, in which the wound is clean and there are no signs of infection, the use of a honey-based dressing may be unnecessary and could introduce unwanted antimicrobial agents. Hydrogel dressings are designed to provide moisture to dry wounds and promote autolytic debridement. However, in this scenario, the wound is dry, so the additional moisture provided by a hydrogel dressing may not be necessary and could lead to maceration of the surrounding skin.

Correct answer: Registered nurse 

Registered Nurses (RNs) are often the primary caregivers in hospital settings, providing round-the-clock care and monitoring of patients. They are trained to assess and manage a patient’s health status, including skin integrity and wound conditions. Given their frequent and close observations and their responsibility in documenting patient care, RNs are typically the first to notice any changes in a patient’s wounds. This includes identifying both new wounds and changes in the condition of existing wounds, making RNs pivotal in initiating further assessments or treatments.

Although physicians are ultimately responsible for diagnosing and overseeing treatment, they are not usually the first to identify changes in a wound. Physicians often rely on nurses to provide initial assessments and updates on patient conditions during their rounds or from nursing reports. Nursing assistants play a critical role in patient care by assisting with basic care needs and daily activities. However, they typically do not have the training or the scope of practice to perform detailed assessments like identifying wound deterioration. They may assist in observing and reporting to nurses, but they are not primarily responsible for initial wound identification. Physical and occupational therapists help patients adapt to their physical limitations, including those caused by wounds, to promote independence and functionality. While they work closely with wound care patients, they aren't usually responsible for initial wound identification.

Correct answer: Hydrogels

Hydrogels are effective for partial- or full-thickness wounds that are dry or have minimal exudate; they are water- or glycerin-based and maintain a moist wound environment. They are often used on leg ulcers, pressure wounds, extravasation injuries, simple-thickness and partial-thickness burns, infected wounds, and necrotic wounds. 

Correct answer: Reduction in collagen and elastin in the dermis leads to thinner, less elastic skin that is more prone to damage

As skin ages, it undergoes intrinsic changes, such as a decrease in collagen and elastin fibers in the dermis, leading to thinner, less elastic skin that is more susceptible to bruising and tearing. This issue is related to the dermal layer, not the epidermal layer. Hyperplasia of the stratum corneum would lead to a thickening of the outermost layer of the skin, not to the thinning and fragility observed in elderly skin. Melanin production affects skin pigmentation and has no direct correlation with the thickness or fragility of the skin. The changes seen in elderly skin are due to structural protein degradation, not melanin production. Hydration of the skin generally improves its barrier function and does not lead to thinning. However, the thinning observed in elderly skin is primarily due to reduced collagen and elastin, not low hydration levels.

Correct answer: Simple open wounds 

Prophylactic antibiotics have not demonstrated a reduction in infection rates in uncomplicated, uncontaminated, non-bite wounds and are therefore rarely indicated for simple open wounds in healthy patients (because those wounds rarely become infected). 

Antibiotics may be indicated for grossly contaminated wounds, saliva bite wounds to an extremity, wounds involving soil or feces, and wounds with devitalized tissue. They may also be indicated for patients with lymphoma. In addition, cutaneous lip wounds and sutured intraoral lacerations should be considered for prophylactic antibiotic use. 

Antibiotics should always be an adjunct to debridement and irrigation and are never a substitute for proper cleaning.

Correct answer: Antimicrobial 

Although the following terms are often used interchangeably, they differ in definition, according to the Food and Drug Administration (FDA):

• antimicrobial: an agent that inhibits or kills microorganisms in a wound or on intact skin
• antiseptic: an agent that stops microorganism growth by either preventing microorganism multiplication (bacteriostatic), or by inhibiting microorganism action with resultant destruction (bactericidal); agents are applied to living tissue
• antibiotic: an organic chemical substance produced by a microorganism that, when diluted in solution, has the ability to kill or prevent the growth of other microorganisms (e.g., penicillin)
• antibacterial agent: an agent that destroys or stops bacterial growth (e.g., bacitracin)

Correct answer: Epidermis 

The epidermis is the outermost skin layer, which is avascular and derived from embryonic ectoderm. The epidermis consists almost entirely of keratinocytes, which are cells that produce keratin, a fibrous protein. 

The epidermal keratinocytes are arranged into five layers. Below the epidermis is the dermis (the vascular structure that supports and nourishes the epidermis). The basement membrane is the structure that separates the epidermis and dermis. The hypodermis (superficial fascia) lies below the dermis and is a layer of loose connective tissue. 

Correct answer: Negative-pressure wound therapy (NPWT) between 75 and 150 mm Hg

Negative Pressure Wound Therapy (NPWT) is designed to establish an environment conducive to wound healing through secondary or tertiary intention. It accomplishes this by preparing the wound bed for closure, reducing swelling, encouraging the formation of granulation tissue and blood flow, and eliminating wound exudate and infectious materials. NPWT, typically applied at pressures ranging between 75 and 150 mm Hg, is the most frequently utilized dressing for traumatic wounds post-debridement of necrotic tissue and eschar, aiding in the extraction of wound effluent.

These negative-pressure dressings are occlusive, effectively shielding wounds from further bacterial contamination or debris. Various types of wound fillers compatible with NPWT are available, including silver-impregnated sponges suitable for infected wounds or those with a substantial bacterial burden.

In instances where NPWT is not suitable, particularly for small, shallow wounds, numerous alternative dressings can be utilized. Preferably, these dressings should reduce bacterial load and facilitate microdebridement, especially in traumatic wound cases.

Correct answer: Hyperglycemia 

Patients may experience a decrease in blood glucose (typically, blood sugar drops 50 points during a 90-minute treatment). Always obtain blood glucose levels from diabetic patients prior to hyperbaric treatment. 

The other choices are potential side effects of HBOT. 

Correct answer: High-voltage pulsed current

High-Voltage Pulsed Current (HVPC) is the preferred type of electrical current in wound care due to its ability to stimulate wound healing. The high-voltage pulses promote cellular activity, accelerate angiogenesis, and increase collagen synthesis while reducing edema and inflammation.

Although Direct Current (DC) can promote healing by stimulating tissue activity, it is not commonly used because it can cause skin irritation and tissue damage due to the buildup of ions. While low-frequency pulsed electromagnetic fields can influence cell behavior and promote healing, they are not an electrical current type used directly in wound care. Instead, they are used in a different therapeutic modality. Alternating Current (AC) can also be used for muscle stimulation and pain relief but is not typically used for wound healing because it lacks the specific high-voltage pulsing properties needed to promote cellular regeneration and wound closure effectively.

Correct answer: Four or fewer

Sensory neuropathy involves the loss of protective sensation. Screening for neuropathy can be done rapidly and reliably using the SWME test (nylon monofilament test). Loss of protective sensation is assessed using a 5.07 monofilament at 10 locations in total, with five key viability sites on each foot. 

The monofilament line used for the test is normally mounted on a rigid paper holder. The line has been standardized to deliver a 10-g force when pushed against an area of the foot. Neuropathy is diagnosed if the patient is unable to feel the 5.07 monofilament. The nylon monofilament test is evaluated according to how many of 10 test sites the patient is able to detect, with <4 indicating decreased sensation. 

Correct answer: Initiate aggressive surgical debridement and apply a moist wound dressing

Aggressive surgical debridement is recommended to remove necrotic tissue, which is nonviable and can harbor bacteria, impeding healing. Removing this tissue can reduce bacterial load and expose healthier tissue that can better respond to treatment. Moist wound dressings are beneficial for maintaining a humid environment conducive to wound healing, facilitating cell migration, and preventing the wound from drying out. This combination is supported by evidence for improving healing rates in diabetic foot ulcers.

Systemic antibiotics are generally reserved for cases when there is evidence of infection spreading beyond the wound itself (e.g., cellulitis, osteomyelitis). The scenario does not specify signs of infection that warrant systemic treatment. Referring for a skin graft is a treatment step generally considered after a wound bed has been prepared and is clean and viable, which is not the case here due to the presence of necrotic tissue and an ongoing non-healing state. This option is premature and skips necessary preliminary wound care steps. The patient's wound has shown minimal improvement over two months, indicating that the current treatment regimen is ineffective. Continuing the same treatment would likely result in continued poor healing.

Correct answer: Decreased urine specific gravity

Patients who are dehydrated can be evaluated by several laboratory tests. Generally, in a dehydrated patient, serum sodium is elevated (hypernatremia), albumin is higher than normal, the BUN-creatinine ratio is increased, and urine specific gravity is increased. 

A decreased urine-specific gravity is not indicative of dehydration.

Correct answer: Proliferative phase 

The proliferative phase is characterized by the formation of granulation tissue. Fibroblasts are actively producing collagen, and new blood vessels form through angiogenesis. These processes provide a scaffold for wound contraction and eventual closure. Keratinocytes also begin to migrate across the wound, initiating the re-epithelialization process.

During the inflammatory phase, the body's primary goal is to clean and prepare the wound for healing. Neutrophils and macrophages remove debris, bacteria, and dead tissue. Although necessary for healing, granulation tissue does not form during this phase. Also known as the remodeling phase, the maturation phase occurs after granulation tissue has filled the wound. During maturation, the wound contracts, and the collagen is remodeled to provide greater tensile strength. Scar formation and remodeling occur at this time rather than during the initial formation of granulation tissue. Sometimes included as a separate phase or as part of the inflammatory phase, coagulation involves hemostasis. Platelet aggregation and clot formation occur to stop bleeding and provide the initial matrix for cell migration, but granulation tissue does not form at this stage.

Correct answer: Bedbound patients should be repositioned at least every two hours

Repositioning every two hours is a widely accepted standard for bedridden patients to reduce continuous pressure on bony prominences, thereby minimizing the risk of pressure injuries. This schedule helps improve blood flow and oxygenation to tissues that would otherwise be under prolonged pressure.

A four-hour interval is too long for immobile patients, as prolonged pressure increases the risk of tissue damage and pressure injuries. A two-hour interval provides more consistent pressure relief. Specialty mattresses can help distribute weight and reduce pressure, but regular turning and shifting remain critical for preventing pressure injuries even with advanced equipment. While dressing changes are crucial for managing existing wounds, they are not directly related to preventing pressure injuries. Frequent turning (repositioning) is the key preventive strategy, as it addresses pressure relief effectively.

Correct answer: Osteomyelitis 

Osteomyelitis is an infection in the bone. It can be caused by a bloodstream infection spreading to the bone or by exposure of the bone through a break in the skin. It can be acute or chronic, and symptoms may vary for each type. In the acute setting, osteomyelitis should be considered when the following symptoms are present: fever, high WBC, high Erythrosedimentation Rate (ESR), and an ulcer to the bone or bony exposure. Patients with T2DM are at high risk of developing osteomyelitis.

The other answer choices do not fit this patient's presentation. 

Correct answer: Educate the nurse to perform a thorough wound assessment and document findings, including size, drainage, and odor

Educating the nurse to conduct a comprehensive assessment and document findings is essential because it provides a thorough understanding of the wound condition and informs treatment decisions. A deep leg wound with increased pain, redness, and a foul odor is concerning, especially in diabetic patients who are at high risk of infection. Proper wound assessment helps identify potential infection signs, guiding further clinical decisions, such as ordering cultures, consulting a physician, and selecting appropriate treatment.

Reassuring the nurse that pain and redness are normal in diabetic wounds while recommending standard care is incorrect because these symptoms could signify infection, and complacency might lead to a lack of necessary intervention. Such advice ignores critical clinical signs and could delay appropriate treatment. Advising the nurse to apply a strong antiseptic solution and cover the wound immediately is inappropriate because it skips the essential step of assessment. Without an understanding of the wound's exact status, administering strong antiseptics might cause further irritation or mask infection symptoms. A thorough assessment should always precede any intervention. Suggesting the nurse consult a physician without conducting an assessment misses the opportunity for prompt, data-driven decisions that can be made based on the initial evaluation. While involving a physician is important, a preliminary assessment ensures the physician has relevant clinical information, streamlining decision-making and optimizing care.

Correct answer: To provide additional support for the patient in adhering to the treatment plan

Involving family members in wound care education helps them understand how to assist the patient with their treatment plan. This additional support can be critical for patients who need help adhering to wound care routines, as family members often play a crucial role in encouraging consistent care and can provide reminders or assistance with daily tasks. 

Involving family members may improve adherence, reducing complications, but it's not specifically aimed at minimizing future medical interventions. Follow-up visits are still important for evaluation and adjustment of the treatment plan. While family members do gain medical knowledge, this isn't the primary goal. The focus is on practical support for the patient rather than expanding the family members' medical expertise beyond what's necessary for daily care. Expecting family members to handle all wound care needs independently is unrealistic and could result in improper care. Family involvement should supplement professional medical care, not replace it entirely.

Correct answer: Immediately 

Depending on the health care system, the appropriate action to take when a patient is screened as being malnourished (or at risk) is referring the patient to a dietician, notifying the provider of the findings, and or calling the nutritional support team. A malnutrition care plan should be implemented immediately upon diagnosis of malnutrition.