**Wound Care and Pressure Injury Management
for Nursing Certification (CWCN) Exam: Evidence-
Based Practice**
---
**Question 1**
A nurse is assessing a pressure injury on a client's sacrum. The wound bed is 100% covered with black,
hard, dry necrotic tissue. Which of the following is the correct stage for this pressure injury?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
💫ANSWER✔️✔️: D. Unstageable pressure injury. The wound base is covered by eschar (black, hard, dry
necrotic tissue) which prevents assessment of the depth of tissue loss. Once the eschar is removed (if
clinically appropriate), the injury can be staged as stage 3 or 4. Stage 2 is partial thickness. Stage 3 is full
thickness without exposed bone, tendon, or muscle. Stage 4 is full thickness with exposed bone, tendon,
or muscle.
💫RATIONALE✔️✔️: The nurse should not remove eschar over the heel unless there is drainage,
fluctuance, or edema (stable eschar on the heel can be left in place). The nurse should consult a wound
care specialist. Pressure injuries are staged using the NPUAP (now NPIAP) system.
---
,**Question 2**
A nurse is assessing a pressure injury on a client's coccyx. The wound bed is pink, moist, and has 50%
granulation tissue. The wound depth is 2 cm, and there is no exposed bone or tendon. Which of the
following is the correct stage for this pressure injury?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
💫ANSWER✔️✔️: B. Stage 3 pressure injury. Full-thickness tissue loss with visible fat, granulation tissue,
and rolled edges (epibole). No exposed bone, tendon, or muscle. Stage 2 is partial thickness (intact or
ruptured blister, shallow open ulcer). Stage 4 has exposed bone, tendon, or muscle. Unstageable has
eschar or slough covering the base.
💫RATIONALE✔️✔️: The nurse should measure the wound (length, width, depth), assess for undermining
and tunneling, and document the percentage of granulation tissue, slough, and eschar. The nurse should
use a wound dressing that maintains a moist environment (hydrocolloid, foam, alginate).
---
**Question 3**
A nurse is assessing a pressure injury on a client's heel. The wound base is covered with yellow, stringy,
moist necrotic tissue. Which of the following terms describes this tissue?
A. Eschar
B. Slough
C. Granulation tissue
D. Epibole
,💫ANSWER✔️✔️: B. Slough. Slough is yellow, tan, or white necrotic tissue that is moist, stringy, and
adherent. Eschar (A) is black, brown, or tan necrotic tissue that is dry and hard. Granulation tissue (C) is
red, moist, and granular (bumpy). Epibole (D) is rolled edges (epithelial cells that have rolled down into
the wound, preventing healing).
💫RATIONALE✔️✔️: Slough should be debrided (autolytic, enzymatic, mechanical, or sharp debridement)
to promote healing. The nurse should select a dressing that promotes autolytic debridement (hydrogel,
hydrocolloid, or calcium alginate). The nurse should also assess for infection (foul odor, increased
drainage, erythema).
---
**Question 4**
A nurse is assessing a pressure injury on a client's ischium. The wound has a deep tunnel (sinus tract) at
the 3 o'clock position measuring 4 cm. Which of the following is the correct term for this finding?
A. Undermining
B. Tunneling
C. Epibole
D. Maceration
💫ANSWER✔️✔️: B. Tunneling. Tunneling (sinus tract) is a channel that extends from the wound edge
into the subcutaneous tissue or deeper. Undermining (A) is tissue destruction under intact skin at the
wound edge (probe under the edge). Epibole (C) is rolled edges. Maceration (D) is softening of skin from
moisture.
💫RATIONALE✔️✔️: The nurse should measure the tunnel depth (in centimeters) and direction (using a
clock face). The nurse should loosely pack the tunnel with an appropriate dressing (e.g., calcium alginate
or hydrofiber) to absorb exudate and prevent dead space. The nurse should avoid overpacking.
---
, **Question 5**
A nurse is assessing a pressure injury on a client's trochanter. The wound edge is undermined at the 6
o'clock position for 3 cm. Which of the following dressings is most appropriate for the undermined area?
A. Hydrocolloid dressing
B. Foam dressing
C. Calcium alginate or hydrofiber dressing (packed lightly)
D. Transparent film
💫ANSWER✔️✔️: C. Calcium alginate or hydrofiber dressing packed lightly into the undermined area to
absorb exudate and prevent dead space. Hydrocolloid (A) and foam (B) are for flat wounds. Transparent
film (D) is for superficial wounds or as a secondary dressing. The nurse should also measure the
undermined depth. The dressing should be changed when saturated (usually daily).
💫RATIONALE✔️✔️: The nurse should also assess for signs of infection (foul odor, increased drainage,
erythema). The nurse should not overpack the undermined area.
---
**Question 6**
A nurse is assessing a stage 3 pressure injury on a client's sacrum. The wound bed is red, moist, and has
a bumpy appearance. Which of the following terms describes this tissue?
A. Slough
B. Eschar
C. Granulation tissue
D. Epithelial tissue
for Nursing Certification (CWCN) Exam: Evidence-
Based Practice**
---
**Question 1**
A nurse is assessing a pressure injury on a client's sacrum. The wound bed is 100% covered with black,
hard, dry necrotic tissue. Which of the following is the correct stage for this pressure injury?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
💫ANSWER✔️✔️: D. Unstageable pressure injury. The wound base is covered by eschar (black, hard, dry
necrotic tissue) which prevents assessment of the depth of tissue loss. Once the eschar is removed (if
clinically appropriate), the injury can be staged as stage 3 or 4. Stage 2 is partial thickness. Stage 3 is full
thickness without exposed bone, tendon, or muscle. Stage 4 is full thickness with exposed bone, tendon,
or muscle.
💫RATIONALE✔️✔️: The nurse should not remove eschar over the heel unless there is drainage,
fluctuance, or edema (stable eschar on the heel can be left in place). The nurse should consult a wound
care specialist. Pressure injuries are staged using the NPUAP (now NPIAP) system.
---
,**Question 2**
A nurse is assessing a pressure injury on a client's coccyx. The wound bed is pink, moist, and has 50%
granulation tissue. The wound depth is 2 cm, and there is no exposed bone or tendon. Which of the
following is the correct stage for this pressure injury?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
💫ANSWER✔️✔️: B. Stage 3 pressure injury. Full-thickness tissue loss with visible fat, granulation tissue,
and rolled edges (epibole). No exposed bone, tendon, or muscle. Stage 2 is partial thickness (intact or
ruptured blister, shallow open ulcer). Stage 4 has exposed bone, tendon, or muscle. Unstageable has
eschar or slough covering the base.
💫RATIONALE✔️✔️: The nurse should measure the wound (length, width, depth), assess for undermining
and tunneling, and document the percentage of granulation tissue, slough, and eschar. The nurse should
use a wound dressing that maintains a moist environment (hydrocolloid, foam, alginate).
---
**Question 3**
A nurse is assessing a pressure injury on a client's heel. The wound base is covered with yellow, stringy,
moist necrotic tissue. Which of the following terms describes this tissue?
A. Eschar
B. Slough
C. Granulation tissue
D. Epibole
,💫ANSWER✔️✔️: B. Slough. Slough is yellow, tan, or white necrotic tissue that is moist, stringy, and
adherent. Eschar (A) is black, brown, or tan necrotic tissue that is dry and hard. Granulation tissue (C) is
red, moist, and granular (bumpy). Epibole (D) is rolled edges (epithelial cells that have rolled down into
the wound, preventing healing).
💫RATIONALE✔️✔️: Slough should be debrided (autolytic, enzymatic, mechanical, or sharp debridement)
to promote healing. The nurse should select a dressing that promotes autolytic debridement (hydrogel,
hydrocolloid, or calcium alginate). The nurse should also assess for infection (foul odor, increased
drainage, erythema).
---
**Question 4**
A nurse is assessing a pressure injury on a client's ischium. The wound has a deep tunnel (sinus tract) at
the 3 o'clock position measuring 4 cm. Which of the following is the correct term for this finding?
A. Undermining
B. Tunneling
C. Epibole
D. Maceration
💫ANSWER✔️✔️: B. Tunneling. Tunneling (sinus tract) is a channel that extends from the wound edge
into the subcutaneous tissue or deeper. Undermining (A) is tissue destruction under intact skin at the
wound edge (probe under the edge). Epibole (C) is rolled edges. Maceration (D) is softening of skin from
moisture.
💫RATIONALE✔️✔️: The nurse should measure the tunnel depth (in centimeters) and direction (using a
clock face). The nurse should loosely pack the tunnel with an appropriate dressing (e.g., calcium alginate
or hydrofiber) to absorb exudate and prevent dead space. The nurse should avoid overpacking.
---
, **Question 5**
A nurse is assessing a pressure injury on a client's trochanter. The wound edge is undermined at the 6
o'clock position for 3 cm. Which of the following dressings is most appropriate for the undermined area?
A. Hydrocolloid dressing
B. Foam dressing
C. Calcium alginate or hydrofiber dressing (packed lightly)
D. Transparent film
💫ANSWER✔️✔️: C. Calcium alginate or hydrofiber dressing packed lightly into the undermined area to
absorb exudate and prevent dead space. Hydrocolloid (A) and foam (B) are for flat wounds. Transparent
film (D) is for superficial wounds or as a secondary dressing. The nurse should also measure the
undermined depth. The dressing should be changed when saturated (usually daily).
💫RATIONALE✔️✔️: The nurse should also assess for signs of infection (foul odor, increased drainage,
erythema). The nurse should not overpack the undermined area.
---
**Question 6**
A nurse is assessing a stage 3 pressure injury on a client's sacrum. The wound bed is red, moist, and has
a bumpy appearance. Which of the following terms describes this tissue?
A. Slough
B. Eschar
C. Granulation tissue
D. Epithelial tissue
