NSG520 MODULE 2 | REALIZEIT |
HERZING UNIVERSITY MSN-DE
ACTUAL EXAM PAPER 2026
QUESTIONS WITH ANSWERS GRADED
A+
◍ What are 3 pressure related factors that contribute to pressure ulcer
development?.
Answer: 1. Pressure Intensity2. Pressure Duration3. Tissue Tolerance
◍ How does pressure lead to tissue ischemia?.
Answer: If pressure applied over a capillary exceeds normal capillary
pressure and the vessel is occluded for a prolonged time
◍ What is the primary objective of Module 2?.
Answer: To use organizational skills such as delegation, prioritization, and
efficient use of resources.
◍ What is critical thinking in nursing?.
Answer: The ability to think systematically and logically, questioning and
reflecting on the reasoning process.
◍ What are the challenges of nursing in the 21st century?.
Answer: Advances in technology, increased acuity in hospitalized patients,
an aging population, and lack of resources to train new nurses.
◍ What is the first step in the nursing process?.
Answer: Assessment.
◍ What types of information are gathered during assessment?.
Answer: Objective information (facts) and subjective information (opinions
, or feelings).
◍ What occurs is tissue ischemia is left untreated?.
Answer: tissue death
◍ Does blanching occur in dark skinned patients?.
Answer: No, blanching does not occur but color, texture and temp may
differ from surrounding area
◍ What does pressure duration assess?.
Answer: Low and extended pressures- Low pressure over a prolonged time
causes tissue damage- Extended pressure occludes blood flow and nutrients
causing tissue death
◍ What are the five dimensions of data gathering in nursing assessment?.
Answer: Physiological, Psychological, Sociocultural, Spiritual, and
Developmental.
◍ What is tissue tolerance?.
Answer: the ability of tissue to endure pressure which is dependent on the
integrity of the tissue and supporting structures
◍ What are risk factors of pressure injuries?.
Answer: ◦Impaired sensory perception◦Impaired mobility◦Alteration in
LOC◦Shear◦Friction◦Moisture
◍ What should the nurse look for when assessing a pressure injury?.
Answer: Wound location, staging, type and approximate percentage of tissue
in wound bed, wound dimensions (sinus tracts and tunneling), exudate
description and condition of surrounding skin
◍ stage 1 pressure injury.
Answer: Intact skin with nonblanchable redness
◍ stage 2 pressure injury.
Answer: partial thickness skin loss involving epidermis, dermis or both and,
shallow abrasion or open blister looking
◍ stage 3 pressure injury.
, Answer: full thickness skin loss extending to SQ, crater looking
◍ What is the purpose of analyzing and interpreting cues in nursing?.
Answer: To identify problems and prioritize patient care based on
assessment data.
◍ stage 4 pressure injury.
Answer: full thickness with exposed bone, muscle or tendon and may have
eschar
◍ What is the difference between actual problems and risk problems in
nursing?.
Answer: Actual problems are present, while risk problems could develop if
not addressed.
◍ What is Maslow's hierarchy of needs?.
Answer: A framework prioritizing human needs from physiological to
self-actualization.
◍ What characteristics does stage 3 and 4 pressure injuries share?.
Answer: They may have slough, undermining and tunneling present
◍ A nurse states slough is present in a stage 3 pressure injury. What should the
student nurse expect to see?.
Answer: A yellow or white, stringy substance attached to wound bed
◍ A nurse states eschar is present in a stage 4 pressure injury. What should the
student nurse expect to see?.
Answer: brown or black necrotic tissue
◍ Unstageable/Unclassified Pressure Ulcer.
Answer: Tissue loss but depth unknown because wound bed is obscured by
slough and/or eschar
◍ What are SMART goals in nursing?.
Answer: Goals that are Specific, Measurable, Achievable, Relevant, and
Time-based.
◍ What is the role of delegation in nursing?.
, Answer: The process of assigning part of your responsibility to another
qualified person in a specific situation.
◍ A patient has an unstageable pressure ulcer but refuses treatment and states
"it will heal on its own". What education should the nurse provide?.
Answer: Slough and eschar must be removed by a clinician to determine the
stage and in order for healing to occur
◍ What are the five rights of delegation?.
Answer: Right task, Right circumstance, Right person, Right directions and
communication, Right supervision and evaluation.
◍ What is reflective practice in nursing?.
Answer: A cognitive skill that involves consciously examining one's beliefs
and experiences to improve patient care.
◍ suspected deep tissue injury.
Answer: Purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft tissue from pressure
and/or shear. Depth unknown
◍ What are some reflection questions for nurses?.
Answer: Questions about patient interactions, assumptions about patient
knowledge, and challenges faced in patient education.
◍ A nurse is assessing a wound and notes the presence of granulation tissue.
What should the student nurse expect to see?.
Answer: Red, moist tissue which indicates progression toward healing
◍ What is the significance of evaluation in the nursing process?.
Answer: To determine if goals and expected outcomes are achieved and to
adjust the care plan as needed.
◍ What should the nurse document when assessing exudate?.
Answer: Amount, color, consistency and odor
◍ What is the NCJMM?.
Answer: Nursing Clinical Judgment Measurement Model, a framework for
HERZING UNIVERSITY MSN-DE
ACTUAL EXAM PAPER 2026
QUESTIONS WITH ANSWERS GRADED
A+
◍ What are 3 pressure related factors that contribute to pressure ulcer
development?.
Answer: 1. Pressure Intensity2. Pressure Duration3. Tissue Tolerance
◍ How does pressure lead to tissue ischemia?.
Answer: If pressure applied over a capillary exceeds normal capillary
pressure and the vessel is occluded for a prolonged time
◍ What is the primary objective of Module 2?.
Answer: To use organizational skills such as delegation, prioritization, and
efficient use of resources.
◍ What is critical thinking in nursing?.
Answer: The ability to think systematically and logically, questioning and
reflecting on the reasoning process.
◍ What are the challenges of nursing in the 21st century?.
Answer: Advances in technology, increased acuity in hospitalized patients,
an aging population, and lack of resources to train new nurses.
◍ What is the first step in the nursing process?.
Answer: Assessment.
◍ What types of information are gathered during assessment?.
Answer: Objective information (facts) and subjective information (opinions
, or feelings).
◍ What occurs is tissue ischemia is left untreated?.
Answer: tissue death
◍ Does blanching occur in dark skinned patients?.
Answer: No, blanching does not occur but color, texture and temp may
differ from surrounding area
◍ What does pressure duration assess?.
Answer: Low and extended pressures- Low pressure over a prolonged time
causes tissue damage- Extended pressure occludes blood flow and nutrients
causing tissue death
◍ What are the five dimensions of data gathering in nursing assessment?.
Answer: Physiological, Psychological, Sociocultural, Spiritual, and
Developmental.
◍ What is tissue tolerance?.
Answer: the ability of tissue to endure pressure which is dependent on the
integrity of the tissue and supporting structures
◍ What are risk factors of pressure injuries?.
Answer: ◦Impaired sensory perception◦Impaired mobility◦Alteration in
LOC◦Shear◦Friction◦Moisture
◍ What should the nurse look for when assessing a pressure injury?.
Answer: Wound location, staging, type and approximate percentage of tissue
in wound bed, wound dimensions (sinus tracts and tunneling), exudate
description and condition of surrounding skin
◍ stage 1 pressure injury.
Answer: Intact skin with nonblanchable redness
◍ stage 2 pressure injury.
Answer: partial thickness skin loss involving epidermis, dermis or both and,
shallow abrasion or open blister looking
◍ stage 3 pressure injury.
, Answer: full thickness skin loss extending to SQ, crater looking
◍ What is the purpose of analyzing and interpreting cues in nursing?.
Answer: To identify problems and prioritize patient care based on
assessment data.
◍ stage 4 pressure injury.
Answer: full thickness with exposed bone, muscle or tendon and may have
eschar
◍ What is the difference between actual problems and risk problems in
nursing?.
Answer: Actual problems are present, while risk problems could develop if
not addressed.
◍ What is Maslow's hierarchy of needs?.
Answer: A framework prioritizing human needs from physiological to
self-actualization.
◍ What characteristics does stage 3 and 4 pressure injuries share?.
Answer: They may have slough, undermining and tunneling present
◍ A nurse states slough is present in a stage 3 pressure injury. What should the
student nurse expect to see?.
Answer: A yellow or white, stringy substance attached to wound bed
◍ A nurse states eschar is present in a stage 4 pressure injury. What should the
student nurse expect to see?.
Answer: brown or black necrotic tissue
◍ Unstageable/Unclassified Pressure Ulcer.
Answer: Tissue loss but depth unknown because wound bed is obscured by
slough and/or eschar
◍ What are SMART goals in nursing?.
Answer: Goals that are Specific, Measurable, Achievable, Relevant, and
Time-based.
◍ What is the role of delegation in nursing?.
, Answer: The process of assigning part of your responsibility to another
qualified person in a specific situation.
◍ A patient has an unstageable pressure ulcer but refuses treatment and states
"it will heal on its own". What education should the nurse provide?.
Answer: Slough and eschar must be removed by a clinician to determine the
stage and in order for healing to occur
◍ What are the five rights of delegation?.
Answer: Right task, Right circumstance, Right person, Right directions and
communication, Right supervision and evaluation.
◍ What is reflective practice in nursing?.
Answer: A cognitive skill that involves consciously examining one's beliefs
and experiences to improve patient care.
◍ suspected deep tissue injury.
Answer: Purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft tissue from pressure
and/or shear. Depth unknown
◍ What are some reflection questions for nurses?.
Answer: Questions about patient interactions, assumptions about patient
knowledge, and challenges faced in patient education.
◍ A nurse is assessing a wound and notes the presence of granulation tissue.
What should the student nurse expect to see?.
Answer: Red, moist tissue which indicates progression toward healing
◍ What is the significance of evaluation in the nursing process?.
Answer: To determine if goals and expected outcomes are achieved and to
adjust the care plan as needed.
◍ What should the nurse document when assessing exudate?.
Answer: Amount, color, consistency and odor
◍ What is the NCJMM?.
Answer: Nursing Clinical Judgment Measurement Model, a framework for
