NAWCO WCC Exam Questions

Correct answer: Incidence reports of falls in the facility

Incidence reports of falls in the facility can help identify potential risk factors contributing to wound development, such as mobility issues or environmental hazards. Patient satisfaction surveys provide feedback about patient experiences but do not directly contribute to risk assessment in wound care management. While prevalence data of chronic wounds in the community is valuable for understanding the scope of the issue, it doesn't directly inform risk assessment within a specific care setting. The average length of hospital stay for wound patients is more indicative of treatment outcomes than of risk in wound care management.

Correct answer: 90 minutes

Tourniquets are typically used when bleeding is severe and cannot be controlled by other means, like direct pressure. They are most effective on the limbs, which they can be wrapped around.

Prolonged tourniquet use (as short as 90 minutes) can result in nerve damage, ischemia, and compartment syndrome. Use of a tourniquet for longer than six hours can lead to loss of a limb. 

Correct answer: Full, increased 

Pedal pulses can normally be palpated at both the dorsalis pedis and the posterior tibialis. The presence or absence of palpable pulses is not diagnostic of lower extremity arterial disease (LEAD). A patient with palpable pulses may still have LEAD; if pulses are absent, a handheld Doppler probe must be used to determine the presence or absence of pulses. 

The best way to document pulses in clinical practice is to utilize a 4-point scale (see below) and to specify the type of scale used (e.g., 3+ pedal pulse on a 4-point scale). 

• 4+ = bounding, aneurysmal
• 3+ = full, increased
• 2+ = expected, normal
• 1+ = diminished, barely palpable
• 0 = absent, not palpable (obtain dopplers)

Correct answer: Herpes simplex virus (HSV) 

HSV infections of the epidermis are highly contagious and occur in two groups: HSV-1 (oral herpes), and HSV-2 (genital herpes). Infections have two phases (primary infection and secondary phase). 

A significant inflammatory response develops in the primary infection that extends from the base of the lesions into the dermis, resulting in the classic presentation of uniform, grouped vesicles on an erythematous base. This clinical presentation is a key indicator of HSV and can be confirmed with a Tzanck smear. A Tzanck smear is most reliable when the lesion sampled is a vesicle. The intact vesicle should be deroofed (via a blunt scalpel) so that the vesicular fluid can be cultured and rapidly tested (within a few hours). 

Correct answer: Exposed blood vessels or nerves are present

Enzymatic debridement involves the use of enzymes to break down necrotic tissue without harming viable tissue. However, if there are exposed blood vessels or nerves within the wound, using enzymatic debridement is risky and contraindicated. The enzymes could damage these structures, leading to significant complications such as bleeding or loss of function. Safety in debridement is paramount, and preserving the integrity of exposed vital structures is crucial.

While patients on immunosuppressive therapy are at a higher risk of infection and may have slower healing rates, this is not a contraindication for enzymatic debridement. Proper wound care and monitoring can mitigate these risks, and the use of enzymatic debridement can be beneficial by removing necrotic tissue that could harbor bacteria and exacerbate infection risks.

The location of a wound (on the lower extremity) does not inherently contraindicate enzymatic debridement. Lower extremity wounds, such as those commonly found in patients with venous insufficiency or diabetic ulcers, often benefit from enzymatic debridement to promote healing. Care must be taken to assess the vascular status and overall condition of the limb, but the location alone does not preclude the use of enzymes.

Although PAD complicates wound healing due to poor arterial blood supply, it is not a direct contraindication for enzymatic debridement. In fact, removing necrotic tissue via enzymatic debridement might be necessary to promote healing. It’s essential, however, to coordinate care with vascular medicine and possibly to adjust the treatment strategy to improve arterial flow, ensuring that the wound can receive adequate oxygenation and nutrients after debridement.

Correct answer: Nutritional assessment and protein supplementation 

Nutrition is a key factor in wound healing. Patients with pressure ulcers often have increased nutritional requirements due to the body's need for tissue repair. Poor nutritional status, particularly protein deficiency, can impair wound healing and the immune response. Protein supplementation and a full nutritional assessment are critical first steps because they ensure the body has the necessary nutrients to facilitate wound healing. Addressing malnutrition is evidence-based and essential before proceeding with further interventions.

Sharp/surgical debridement involves removing necrotic tissue to promote a healthier wound bed, but it should not be immediately prioritized in patients with poor nutritional status, as malnutrition increases the risk of complications from surgery. Effective debridement requires a healthy immune response and sufficient protein levels, so nutritional improvement should be addressed first. Wet-to-dry dressings are not a recommended practice for wound management due to their potential to damage healthy tissue and cause pain when removing the dried gauze. They can also be time-consuming and uncomfortable for the patient, making them less favorable than modern wound care products that maintain a moist healing environment. Topical steroids are not typically used in treating pressure ulcers as they can impair the wound-healing process by suppressing the local immune response. They are contraindicated unless the patient has an underlying inflammatory skin condition. Addressing the patient's nutritional status is a much more immediate and effective step to support wound healing.

Correct answer: 200 mL per 24 hours

Fistulas can be classified according to output. A low-output fistula is characterized by <200 mL per 24 hours. 

Correct answer: Negative Pressure Wound Therapy (NPWT) 

Negative Pressure Wound Therapy (NPWT) involves the application of a controlled vacuum to the wound bed. This therapy helps promote healing by reducing edema, increasing blood flow, removing exudate, and drawing the edges of the wound together. The continuous or intermittent vacuum creates an optimal environment for wound healing by keeping the wound moist and stimulating cellular proliferation.

Hyperbaric Oxygen Therapy (HBOT) involves breathing pure oxygen in a pressurized chamber to increase the oxygen concentration in the blood and tissues, which promotes healing. Ultraviolet light therapy uses UV light to kill bacteria and promote wound healing through photochemical reactions. Pulsed lavage is a wound care technique that uses pressurized irrigation to clean the wound and remove debris. It involves the application of a jet of saline or other solutions to the wound bed.

Correct answer: Neuroischemic ulcer 

A neuroischemic ulcer is the most difficult ulcer to treat (and heal) in the foot, occurring in individuals who have both neuropathy and poor circulation. This ulcer has characteristics of a neuropathic ulcer, but microvascular disease makes this ulcer a challenge to heal. 

Often, noninvasive arterial studies demonstrate mild macrovascular disease. The appearance of the foot is consistent with signs of vascular disease as well as severe neuropathy. The wound base is pink mixed with a fibrinous-type tissue that recurs even with sharp debridement. 

Correct answer: Metabolic acidosis frequently occurs.

Metabolic acidosis is a frequent side effect when mafenide is used on burns greater than 25% TBSA. Secondary hyperventilation may result from drug-induced metabolic acidosis secondary to inhibition of carbonic anhydrase. Therefore, a patient's respiratory status and acid-base balance should be monitored while the drug is being used. 

Other adverse effects include pain when applied to partial-thickness burns and a maculopapular rash for any size of burn injury (not just those greater than 25% TBSA). This topical agent should be used primarily on small wounds or for as short a time as possible on large wounds. A 5% solution is also available and approved for use as a prophylactic agent applied as a soak to fresh autografts. 

Correct answer: Discuss and clarify the legal requirements with the management

The first and most constructive step would be to address the issue internally by discussing the legal requirements with the management to align the facility’s documentation practices with state regulations. This approach seeks to rectify the practice without escalating to regulatory bodies or taking drastic personal steps such as resignation, which could be considered later if internal corrections are not implemented.

Correct answer: Arterial insufficiency 

Intermittent claudication is characterized by exercise-induced pain or cramping in the lower extremities due to inadequate blood flow. This symptom indicates arterial insufficiency, or peripheral artery occlusive disease (PAOD). 

Uncontrolled or poorly controlled diabetes and thrombocytosis are risk factors for the development of PAOD. 

Correct answer: Type I

The primary proteins present in the dermis include collagen and elastin. Collagen accounts for approximately 30% of the dermis's volume or 70% of its dry weight. Among the 19 known types of collagen, four are particularly abundant.

Type I collagen is predominantly found in tendons, ligaments, bones, and skin, constituting around 90% of skin collagen. Type II is a major component of cartilage. Type III collagen is prevalent in arteries, the intestine, and the uterus. Type IV collagen is located within the basement membrane of the epidermis. The remaining 15 types are present in significantly lower quantities.

Correct answer: Healing rate during the first 4 weeks of observation

The healing rate during the first 4 weeks of observation has been validated as a predictor of healing outcomes and is steady over the course of healing for venous, diabetic, and pressure ulcers.

Factors that significantly affect healing outcomes include initial size (larger ulcers take longer to heal), duration (ulcers of short duration are most likely to heal), circulation (moderate arterial insufficiency increases the risk of delayed healing), and nutrition (full-thickness pressure ulcers heal faster with proper nutrition).

Correct answer: Verify that the wound dressing change aligns with the established wound care plan

NPs have a broader scope of practice than some other nursing roles, and dressing changes typically fall within this scope. A wound care NP is typically allowed to change wound dressings independently if it's within their scope of practice as long as it aligns with the care plan. The care plan is the guiding document that provides individualized treatment protocols. Following it ensures that the NP provides appropriate care within their scope, avoiding overstepping boundaries.

The presence of a colleague isn't required for the NP to perform dressing changes. The NP's scope allows them to work independently in this regard. A colleague could assist, but it wouldn't be legally necessary to ensure compliance with the scope of practice. NPs generally have the authority to perform wound dressing changes without direct physician supervision, particularly if the procedure falls within their scope and aligns with the care plan. Requiring a physician's direct supervision would be an unnecessary restriction. Waiting for a physician to perform a thorough examination would unnecessarily delay treatment. Immediate care, as specified in the care plan, is vital to managing wound healing, especially in diabetic patients.

Correct answer: Swab of exudate

A wound culture must be taken from clean, healthy-appearing tissue. Because infection involves the tissue, it is important to culture the tissue rather than the pus, slough, eschar, or necrotic material. 

Three techniques are used in the clinical arena to obtain a wound culture: biopsy, needle aspiration culture, and swab culture. The swab technique is the most commonly performed, as it requires the fewest clinical skills and most laboratories are accustomed to performing the analysis. The Levine technique is an approach used for swabbing a wound and involves pressing the tip of the swab into the wound bed and rotating the applicator to elicit a tissue fluid sample for analysis. 

Correct answer: The patient's prealbumin level increases

Prealbumin is a marker of nutritional status, and its increase (not decrease) suggests improved protein synthesis and nutritional intake, which are essential for wound healing. Weight loss in a patient requiring wound healing may suggest inadequate calorie intake or malnutrition, which can impair healing processes. Less hunger does not directly indicate effective nutritional support for wound healing; it could also reflect issues like medication side effects or decreased metabolic rate. Unstable glucose levels can adversely affect wound healing, especially in diabetic patients, and do not suggest that the nutritional support is effective in wound healing. 

Correct answer: To indicate potential underlying complications

Tunneling can suggest more extensive damage to the underlying tissues, possibly resulting from infection, pressure, or other factors. Recognizing and documenting this helps guide appropriate interventions, such as antibiotic therapy or surgical debridement. Tunneling can also signify bacterial infection, as bacteria can create pathways through tissue layers. Early identification and documentation of tunneling can help detect infections sooner, prompting immediate treatment and reducing the risk of further complications.

While tunneling can affect the overall shape of a wound, documenting tunneling is primarily about identifying underlying complications rather than merely tracking shape changes. While dressing type and size might depend on the wound's characteristics, this is not the primary reason for documenting tunneling. It's more about monitoring and treating underlying issues. Tunneling and drainage consistency are separate aspects of wound documentation. Tunneling is more indicative of complications, while drainage consistency provides information about the wound's status. 

Correct answer: Non-enteric fistulas 

NPWT is FDA-approved for use on chronic, acute, traumatic, subacute, and dehisced wounds; partial-thickness burns; ulcers (diabetic or pressure); flaps and grafts once viable tissue is removed; and certain high-risk postoperative surgical incision. This modality is used clinically for wounds of all sizes and depths but most favorably in complicated deep wounds (with the specific goal of promoting wound healing). 

NPWT can be used in wounds with tunneling and undermining or sinus tracts, as long as the wound filler can fill the dead space and is easily retrieved. 

It is contraindicated in the presence of untreated osteomyelitis, necrotic tissue, exposed blood vessels, exposed organs, nonenteric or unexplored fistulas, and malignancy in the wound. 

Correct answer: Multilayer bandaging compression therapy

Compression therapy with multilayer bandaging is considered the gold standard for managing venous leg ulcers. This therapy helps reduce venous hypertension, improve blood return, and minimize edema, which collectively promotes healing. Compression directly targets the underlying cause of venous ulcers: improper venous return due to valve dysfunction in the veins. Current evidence-based protocols support compression therapy as essential for both healing and preventing recurrence of venous leg ulcers.

Daily hydrotherapy is not routinely recommended for treating venous ulcers. Overexposure to water could macerate healthy tissue and interfere with the natural wound-healing process. Moreover, hydrotherapy does not address the root cause of venous leg ulcers, which is venous insufficiency. Sharp (surgical) debridement is not always necessary for venous ulcers, particularly if the wound is not heavily necrotic. While some debridement may be beneficial for nonviable tissue removal, compression therapy is still crucial to promote blood flow and reduce edema, which aids wound healing. Growth factors can help promote healing in chronic wounds, but they should be considered as a complementary treatment rather than a first-line option because they do not directly address the primary issue of venous hypertension. Compression remains the primary intervention to resolve edema and promote circulation.