Wound, pressure-injury, and ostomy management are frequent med-surg responsibilities the CMSRN tests. Practice the staging, dressing, and stoma-care scenarios below with full rationales.
Question 1
An obese patient with a tracheostomy develops a pressure injury under the tube flange. Which prevention strategy is essential?
- A) A) Applying antibiotic ointment around the stoma twice daily
- B) B) Using foam padding to suspend the flange above the skin✓
- C) C) Rotating the tracheostomy tube 90 degrees every 4 hours
- D) D) Cleansing the site with hydrogen peroxide once per shift
Show rationale
Suspending the flange relieves direct pressure, critical for device-related injuries per NPIAP. Rotation (C) may dislodge the tube. Ointments (A) trap moisture; hydrogen peroxide (D) damages tissue. Obesity increases device-related pressure risk. Prevention focuses on mechanical offloading, not topical agents.
Question 2
For a patient with darkly pigmented skin and a history of malnutrition, which technique best detects stage 1 pressure injury?
- A) A) Palpating for temperature changes over bony prominences✓
- B) B) Using a halogen light to inspect for subtle color shifts
- C) C) Assessing capillary refill time on the sacral area
- D) D) Comparing skin integrity to unaffected contralateral sites
Show rationale
In dark skin, non-blanchable erythema manifests as warmth, edema, or induration—not color change. Palpation detects these cues per NPIAP guidelines. Lighting (B) aids color assessment but is unreliable without palpation. Capillary refill (C) assesses perfusion, not tissue damage. Comparison (D) misses early inflammatory changes. Malnutrition increases risk but doesn’t alter assessment methods.
Question 3
An agitated dementia patient with stage 3 pressure injuries repeatedly attempts to climb over bed rails in a dimly lit isolation room. Which environmental intervention balances safety and autonomy?
- A) A) Applying soft limb restraints and increasing sedation frequency
- B) B) Installing pressure-relieving mattress and using bed exit alarms
- C) C) Lowering the bed to floor level and adding motion-sensor lighting✓
- D) D) Implementing scheduled repositioning and raising all side rails
Show rationale
Low beds reduce fall impact while motion lights address visibility issues without restraints—key in The Joint Commission's restraint reduction initiatives for dementia care. A increases injury risk and violates CMS restraint regulations. B doesn't address the climbing motivation. D's raised rails may increase fall severity. Pressure injury guidelines support low beds for mobility-impaired patients to allow safe self-mobilization.
Question 4
A 72-year-old patient with type 2 diabetes and heart failure is admitted for pneumonia. The nurse observes a shallow open ulcer with pink wound bed and no slough on the sacrum, with partial-thickness skin loss. Which pressure injury stage does this presentation indicate?
- A) A) Stage 1: Non-blanchable erythema of intact skin
- B) B) Stage 2: Partial-thickness skin loss with exposed dermis✓
- C) C) Stage 3: Full-thickness skin loss with visible adipose tissue
- D) D) Unstageable: Full-thickness skin loss obscured by slough/eschar
Show rationale
Stage 2 injuries involve partial-thickness loss of dermis, appearing as a shallow open ulcer with a viable pink wound bed without slough—matching the description. Stage 1 has intact skin; Stage 3 involves deeper tissue (adipose); Unstageable has obscured depth by necrotic tissue. Diabetes increases risk but doesn’t alter staging criteria. NPIAP guidelines emphasize assessing depth and tissue visibility for staging.
Question 5
A patient with a sacral wound vac has "LOW PRESSURE" and "LEAK" alarms activated during ambulation. The dressing edges are intact, but tubing is disconnected from the canister port. How should the nurse respond?
- A) A) Reconnect tubing to the canister and restart suction after resealing the dressing✓
- B) B) Replace the entire dressing and tubing set using sterile technique
- C) C) Silence alarms temporarily and assess for fluid accumulation under the dressing
- D) D) Clamp tubing near the dressing, replace the canister, and restart suction
Show rationale
Disconnected tubing (cue) causes low pressure/leak alarms. Reconnecting restores system integrity efficiently (cue: dressing edges intact). Full dressing replacement (B) is unnecessary without contamination. Silencing alarms (C) delays resolution. Clamping (D) risks contaminating the system. CDC guidelines support minimal intervention for intact dressings.
Question 6
An obese patient (BMI 42) with heart failure develops redness on their sacrum 48 hours post-admission. Skin is intact but warmer than surrounding tissue, with non-blanchable erythema. Which assessment is essential?
- A) A) Measure bilateral calf circumference
- B) B) Assess nutritional albumin/prealbumin levels
- C) C) Perform a 4-hourly Braden Scale reassessment✓
- D) D) Check for fecal incontinence episodes
Show rationale
Non-blanchable erythema indicates Stage 1 pressure injury, requiring frequent risk reevaluation using validated tools like Braden Scale. Option A assesses for DVT, not skin integrity. Option B evaluates nutrition but won't change immediate skin protection needs. Option D addresses incontinence but warmth and erythema suggest pressure, not moisture damage. NPIAP guidelines emphasize serial assessments for early pressure injury.
Question 7
During a callback for a diabetic patient discharged after foot ulcer debridement, the patient reports new erythema extending 2cm around the wound and localized warmth. The patient's temperature is 37.8°C (100°F) orally. Which instruction is most appropriate?
- A) A) Apply ice to the area and monitor for temperature changes
- B) B) Increase insulin dosage by 20% for presumed hyperglycemia
- C) C) Elevate the foot and return to clinic at next scheduled visit
- D) D) Arrive at wound care clinic within 4 hours for assessment✓
Show rationale
Spreading erythema with fever suggests early cellulitis, requiring same-day evaluation per diabetic foot infection guidelines. Option D addresses infection risk promptly. Option A delays treatment and ice may reduce perfusion. Option B incorrectly attributes signs to glucose control. Option C ignores time-sensitive infection cues (erythema spread, low-grade fever) in an immunocompromised patient. The combination of new inflammation and temperature change necessitates urgent re-evaluation.
Question 8
A diabetic patient with a stage III pressure injury expresses cultural reluctance toward protein-rich wound diets. The unit’s evidence-based guideline recommends high-protein nutrition, but the nurse notes limited research in culturally diverse populations. What is the optimal EBP approach?
- A) A) Strictly follow the guideline to ensure consistency with current best evidence
- B) B) Eliminate protein targets entirely to respect the patient’s cultural preferences
- C) C) Collaborate with the dietitian to modify protein sources aligning with cultural preferences✓
- D) D) Delay nutritional interventions until more inclusive research is available
Show rationale
EBP requires integrating patient values with evidence. Imposing guidelines (A) disregards cultural needs. Abandoning evidence-based nutrition (B) risks poor healing. Waiting for ideal research (D) is impractical. Collaborating with dietary experts (C) adapts high-protein evidence to cultural preferences, honoring both EBP pillars and patient autonomy.
Question 9
During a pressure injury CQI project, a nurse suggests involving physical therapists in skin assessments. The team has only included wound care nurses thus far. Which CQI tenet supports this suggestion?
- A) A) Leveraging interprofessional expertise for comprehensive solutions✓
- B) B) Restricting changes to directly involved disciplines
- C) C) Prioritizing speed by minimizing team size
- D) D) Using existing workflows to limit disruption
Show rationale
PTs offer unique mobility insights (cue: skin assessments), embodying CQI’s interprofessional collaboration. Restricting disciplines (B) hinders holistic analysis. Speed (C) and workflow preservation (D) may sacrifice thoroughness. IHI guidelines advocate cross-functional teams for complex issues.
Question 10
A case manager coordinates care for a Spanish-speaking patient with low health literacy recovering from abdominal surgery. The patient expresses confusion about ostomy care despite interpreter use. Which strategy best addresses health equity?
- A) A) Providing printed educational materials in Spanish before discharge
- B) B) Requesting extended home health visits for hands-on teaching
- C) C) Arranging teach-back sessions using visual aids and simplified language✓
- D) D) Scheduling a family meeting with the wound care nurse present
Show rationale
Teach-back with visuals (C) actively addresses literacy and language gaps, unlike passive materials (A). While home health (B) or family meetings (D) are useful, they don't specifically adapt to literacy needs. The confusion despite interpreter use indicates standard methods failed, requiring culturally responsive techniques per health equity standards. Simplified teach-back ensures comprehension verification.
Question 11
A nurse notes frequent supply shortages of wound vac equipment, causing delayed dressing changes. The materials management department reports budget constraints, and the nurse manager suggests "making do." Which approach follows organizational escalation protocols?
- A) A) Mobilizing nursing staff to share equipment across units informally
- B) B) Submitting a non-formulary supply request through clinical leadership✓
- C) C) Contacting the vendor directly for emergency donations
- D) D) Alerting hospital administration via anonymous safety hotline
Show rationale
Escalation protocols require formal channels when unit-level resolution fails. Submitting through clinical leadership addresses budget constraints while maintaining hierarchy, as non-formulary requests involve supply chain and financial oversight. Informal sharing (A) circumvents inventory systems and creates documentation risks. Direct vendor contact (C) violates procurement policies. Anonymous reporting (D) bypasses clinical leaders who can contextualize clinical impact. The wound vac shortage directly affects patient outcomes, justifying formal resource requests.
Question 12
A postoperative patient on warfarin for atrial fibrillation develops a warm, erythematous incision with white exudate. International Normalized Ratio (INR) is 3.8. Which collaborative action is essential?
- A) A) Hold warfarin and initiate therapeutic enoxaparin
- B) B) Obtain wound culture before antibiotic administration✓
- C) C) Consult physical therapy for early mobility promotion
- D) D) Apply warm compresses four times daily to incision
Show rationale
Culture-guided antibiotics are critical for SSI management (IDSA guidelines). Elevated INR increases bleeding risk with debridement but doesn't negate culture need. Anticoagulation adjustment (A) may be needed but follows infection confirmation. Early mobility (C) may spread infection with active exudate. Warm compresses (D) increase bacterial proliferation in established infection. The exudate and anticoagulation cues make targeted therapy essential.
Question 13
A construction worker with a new colostomy grimaces during wound care teaching, muttering, "Just give me the instructions." The nurse notes he learns best hands-on. Which action aligns with adult learning principles?
- A) A) Simplify verbal explanations using construction analogies for each step
- B) B) Have him perform pouch changes with guided practice immediately✓
- C) C) Show an instructional video followed by written quizzes
- D) D) Reassure him that skills improve with time and provide diagrams
Show rationale
Kinesthetic preference (cue) and immediate need for practical skills justify active participation per Kolb's experiential learning. Option A uses relevant analogies but remains passive. Option C ignores disdain for theory-based methods (cue: "just give instructions"). Option D delays skill-building despite observed discomfort. Hands-on practice respects autonomy while addressing urgency (new colostomy).
Question 14
A patient with a new ileostomy and depression refuses to empty the pouch, stating, "It's disgusting." Which approach supports self-management?
- A) A) Arrange home health visits for ostomy care indefinitely
- B) B) Explore odor-control products during desensitization practice✓
- C) C) Schedule a peer visit from an ostomy support group member
- D) D) Prescribe antidepressant medication before resuming teaching
Show rationale
Addressing disgust directly with practical solutions promotes independence. Option A fosters dependence. Option C is valuable but secondary to hands-on skill-building. Option D delays essential self-care. CMSRN competencies prioritize integrating psychological support with skill acquisition.
Question 15
A stroke patient with left hemiparesis and unilateral neglect resists repositioning. Which approach reduces agitation while preventing pressure injuries?
- A) A) Scheduled 2-hour turns toward the unaffected side
- B) B) Hourly shifts to the affected side with mirrors✓
- C) C) Continuous lateral rotation therapy
- D) D) Supine with frequent shoulder adjustments
Show rationale
Turning toward the affected side with mirrors promotes sensory input to reduce neglect-related agitation. Hourly turns address high immobility risk. Option A's 2-hour interval increases pressure injury risk. Option C's automated rotation may heighten confusion. Option D neglects lateral pressure redistribution. The cues (hemiparesis + neglect) require integrating neurological rehabilitation principles with skin protection.
