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Critical Analysis of a Wound Care Certification Question

Thompson, Donna L.; Durkop-Scott, Kay L.

Journal of Wound, Ostomy and Continence Nursing: September/October 2012 - Volume 39 - Issue 5 - p 552–554
doi: 10.1097/WON.0b013e318264c12b
Getting Ready For Certification
Free

Donna L. Thompson, MSN, CRNP, FNP-BC, CCCN, Continence Specialist/Nurse Practitioner, Urology Health Specialists, LLC, Drexel Hill, Pennsylvania.

Kay L. Durkop-Scott, BSN, RN, CWOCN, Inpatient Wound Ostomy Continence Nurse, Centura Health Porter Adventist Hospital, Denver, Colorado

Correspondence: Donna L. Thompson, MSN, CRNP, FNP-BC, CCCN, WOCNCB Office, 555 East Wells St, 1100, Milwaukee, WI 53202 (info@wocncb.org).

The authors declare no conflict of interest.

Accurate, ongoing wound evaluation is a key component of an effective plan of care. The Wound, Ostomy and Continence Nursing Certification Board (WOCNCB)–certified nurse uses critical thinking in wound management with consistent, regular wound evaluations, along with evaluation of relevant data such as laboratory studies, nutrition, mobility, and incontinence, which may impact progress toward healing. Ongoing assessment of the wound requires a broad understanding of basic nursing care, and specialty knowledge of the WOCNCB-certified nurse is required. This process of continuous evaluation and outcome measurement is but one of the many reasons the WOCNCB-certified nurse is such a respected member of the wound care team.

These same skills can be used when answering certification examination questions. The first step in effective test taking is to critically examine the question: carefully reading the stem (body) of the question and determine what information it provides. For example, when reading a question about a pressure ulcer, the test taker should have knowledge about the relationship between wound healing and the presence of adequate oxygenation and nutrition. As a result, the question may assume that the test taker knows that a low transferrin level indicates a nutrition problem and ask about interventions that will enhance protein intake. Alternatively, a question may ask the test taker to identify a patient at highest risk for pressure ulcer development related to a specific chronic disease or diagnosis. Knowledge of basic nursing (the chronic disease) and wound healing (oxygenation and nutrition) aids the individual to recognize that a patient with pulmonary disease is at high risk for developing a pressure ulcer.

Following evaluation of the stem, the test taker must reevaluate the question again in relation to each potential answer. Read each option carefully and remove options from consideration that are clearly incorrect or seem to be out of context to the situation presented in the stem. Rephrase each option as a statement and identify the options that seem most true or more precise. Look for a key word in the stem such as nutrition and make sure that your selected answer clearly addresses nutrition. In most cases, the test taker will be able to eliminate at least half of the potential answers. When confronted with 2 options that both seem to be correct, reevaluate each option in relation to the problem or situation stated in the stem. Does the option under consideration completely address the question? Do you need to make an assumption to answer the question? Is that assumption an obvious one that all certified WOC nurses should know? If not, that option may not be the correct one. Remember that questions are not designed to “trick” test takers. Certification examination questions are developed by experienced WOCNCB-certified nurses and carefully reviewed by the Board's WOC Examination and Item Review Committees in close consultation with a psychometrician (PhD-prepared testing expert). In most cases, if a question is suspected to be a “trick” question, the test taker is reading too much into the question by attaching his or her own detailed “what if” scenarios that would make that option correct.

The WOCNCB-certified nurse is an expert in critically analyzing a wound and its potential to heal. Using those same critical thinking skills will help you be successful on the WOCNCB Wound certification examination and achieving Wound Care Certification.

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Practice Questions

  1. During a routine dressing change, the nurse observes the wound bed to be covered with fragile, moist, red granulation tissue, which has grown above skin level. The current dressing orders are for hydrocolloid dressing, changed every 3 days. Which of the following dressings is MOST appropriate for the nurse to recommend at this time?
    1. Polyurethane foam
    2. Moist gauze
    3. Transparent film
    4. Hydrogel sheet
  2. Which of the following Ankle-Brachial Index (ABI) values indicates the best potential for lower extremity wound healing?
    1. 0.4
    2. 0.7
    3. 0.9
    4. 1.5
  3. A 73-year-old woman, 5 ft 2 inches tall, weighing 113 kg (body mass index 46), with respiratory failure and sepsis, is admitted to the intensive care unit. She is intubated and sedated. Which of the following is one of the MOST common pressure ulcer development locations for this patient?
    1. Buttocks
    2. Ischial tuberosities
    3. Trochanters
    4. Occiput

Question 1: This analysis question asks you to select (and apply as appropriate) dressings for containment of drainage and/or maintenance of moist wound surface. The correct answer is A, Polyurethane foam. Hypergranulation tissue or hyperplasia is the excessive growth of the granulation tissue above the level of the skin. This overgrowth of the granulation tissue means that the wound is overly moist. Wound dressings are selected to maintain a moist, not wet, wound environment. The stem of the question does not give any further information regarding the wound or the rationale of why a hydrocolloid was being used. Based on the information available, the wound nurse would conclude the wound healing cascade as being compromised by the impermeable components of the hydrocolloid. The wound nurse would then select the best alternate dressing to absorb excess moisture. Polyurethane foam is the most appropriate choice as the primary function of foam is absorption. Moist gauze dressings add more moisture to the wound, can dry out easily, and are labor intensive. A transparent film and hydrogel sheet have little or no absorbent capacity.

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Reference

Rolstad B, Bryant R, Nix D. Topical management. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:296–302.

Content Outline Placement: 1B4a

Question 2: This recall question asks you to recommend and interpret ABI. The correct answer is C, 0.9. When reading this question, the test taker should pay careful attention to key words. When the word best is used, the test taker is cued to understand that wound healing is not guaranteed, but optimal arterial perfusion of the lower extremity is best indicated by an ABI of 1.0. The ABI is a noninvasive test comparing systolic blood pressure in the lower extremity with the upper extremity (systolic ankle pressure divided by systolic arm pressure). Recalling this equation, the test taker can then eliminate options. An ABI of 0.9 indicates that the patient's arterial perfusion in the lower limbs is very similar to the upper limbs and is the best choice; 0.4 would indicate critical ischemia; 0.7 is borderline perfusion, and an ABI of 1.5 may be falsely elevated due to noncompressible vessels and further testing would be required to adequately evaluate perfusion.

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Reference

Doughty D. Arterial ulcers. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:184–186.

Content Outline Placement: 1D1e2

Question 3: This application question asks you to conduct and interpret a risk assessment. The correct answer is A, buttocks. The bariatric patient population presents unique challenges in pressure ulcer prevention. The certified wound care nurse must be alert to positioning dilemmas of the bariatric patient that can occur in any healthcare setting. The sacrum/coccyx, heels, and buttocks are the most common locations for hospital-acquired pressure ulcers in this patient population. The buttocks of the bedbound bariatric patient are in maximum contact with the bed surface due to the fleshy atypical body contours caused by high adipose tissue concentration. In this ICU patient, damage from shear and pressure can occur when the buttocks are inadequately positioned and the skin can become folded and compressed. Ischial tuberosity ulcers occur from prolonged erect seating in chair or wheelchair. This could apply to a bariatric patient without an adequate pressure relief cushion but does not apply to this patient situation. Trochanter ulcers occur when individuals rest in a lateral position, are allowed to lie in that position for long periods of time, or have severe contractures and are only able to be positioned laterally. In the bariatric patient, pressure ulcers can occur on hips or lateral thighs from side rails and armrests of improperly sized equipment but this also does not apply to this patient. The occiput is the most common location for pressure ulcer development in infants and children so the test taker can quickly eliminate this option.

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References

Black J, Black S. Reconstructive surgery. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:465.

Camden SG. Skin care needs of the obese patient. In:Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:478–479.

Coha T, Wysocki A. Skin care needs of the pediatric and neonatal patient. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:497.

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. http://www.npuap.org/Final_Quick_Treatment_for_web_2010.pdf. pages 21–22.

VanGilder C, MacFarlane G, Lachenbruch C. BMI, weight and pressure ulcer prevalence. J Nurs Care Qual. 2009;24(2):127–135.

Content Outline Placement: 1C1a

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Our Name...Our Brand...Our Future

Diana L. Gallagher, MS, RN, CWOCN, CFCN

The value of a name cannot be underestimated. A name conveys identity and commitment. It honors our history and our heritage. Properly used, a name can promise quality, value, and dependability.

Over time, one's identity can become blurred. Pioneer Norma Gill's role changed from an ostomy technician to an enterostomal therapist and paved a future for enterostomal therapy nurses and later wound ostomy continence nurses. The identities of our society and certification board have also evolved over time. These changes, compounded by competition, have left some consumers confused. The Wound, Ostomy and Continence Nurses (WOCN) Society is a professional nursing society providing support, education, and member benefits. The acronym WOCN identifies our professional society, and individuals should not use “WOCN” to identify his or her professional role. The Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) provides certification to validate nurses' knowledge and competence. They are completely independent organizations but supportive of one another's missions. Nurses who have completed formal specialty education should describe themselves as WOC nurses until they earn their coveted “C” by becoming WOCNCB certified. They then join the more than 6000 nurses who identify themselves as WOCNCB-certified nurses, and if tri-certified, as a CWOCN. Please join our mutual effort to clarify our identities. When used correctly, our name says it all.

The WOCN Society, in collaboration with the WOCNCB, has addressed this challenge with a position paper. Together, we are determined to help members and stakeholders differentiate between WOC nurses, the WOCN Society, the WOCNCB, and the nurses the WOCNCB certifies. Like our past journey, this path will lead us to a better, brighter, and clearer future. Go to http://www.wocncb.org/resources/position-statements.php to view the position paper.

Copyright © 2012 by the Wound, Ostomy and Continence Nurses Society