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JOYCE UNIVERSITY | NURSING FUNDAMENTALS
(NUR125) EXAM 2 –| 2026/2027 QUESTION BANK
WITH VERIFIED SOLUTIONS.
Question 1 — Pressure Injury Staging (Multiple-Choice)
A 78-year-old patient with a history of heart failure is admitted after a fall. During skin
assessment, the nurse observes a 3 cm × 2 cm area of non-blanchable erythema over the
patient's right ischial tuberosity. The skin is intact with no blisters, open areas, or drainage.
How should the nurse document this finding?
A. Stage 2 pressure injury
B. Stage 1 pressure injury [CORRECT]
C. Deep Tissue Injury (DTI)
D. Unstageable pressure injury
Rationale: This is a Stage 1 pressure injury, defined as non-blanchable erythema of intact skin.
The key differentiators are: skin remains intact (rules out Stage 2), discoloration is superficial
erythema rather than deep red/maroon/purple (rules out DTI), and the wound bed is fully
visible without slough or eschar (rules out unstageable). In patients with darker skin tones,
the nurse should assess for changes in skin temperature, tissue consistency, and pain, as
erythema may be more difficult to visualize.
Question 2 — Pressure Injury Staging (Multiple-Choice)
During a wound assessment, the nurse observes a full-thickness wound over the sacrum with
visible yellow subcutaneous fat but no exposure of bone, tendon, or muscle. Slough is present
but does not obscure the wound bed. What is the correct staging?
A. Stage 2 pressure injury
B. Stage 3 pressure injury [CORRECT]
C. Stage 4 pressure injury
D. Unstageable pressure injury
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Rationale: This is a Stage 3 pressure injury, defined as full-thickness skin loss in which adipose
tissue (fat) is visible in the ulcer. The wound bed may contain slough, but slough does not
obscure the depth—allowing the nurse to confirm that bone, tendon, and muscle are not
exposed (which would indicate Stage 4). Tunneling or undermining may be present but does
not change the stage. The nurse must document the presence of slough and measure
undermining/tunneling for treatment planning.
Question 3 — Deep Tissue Injury (Multiple-Choice)
A 62-year-old patient with diabetes and peripheral vascular disease is transferred from a long-
term care facility. The nurse notes a 4 cm × 3 cm area of persistent deep maroon discoloration
on the left heel. The skin is intact but feels boggy and warmer than surrounding tissue. The
patient reports significant pain at the site. What is the priority nursing diagnosis?
A. Risk for infection related to open wound
B. Acute pain related to Stage 2 pressure injury
C. Risk for impaired skin integrity related to Deep Tissue Injury [CORRECT]
D. Ineffective tissue perfusion related to arterial insufficiency
Rationale: This is a Deep Tissue Injury (DTI), characterized by persistent non-blanchable deep
red, maroon, or purple discoloration of intact or non-intact skin. The boggy consistency and
pain are hallmark signs of underlying tissue damage. The priority nursing diagnosis is Risk for
impaired skin integrity because the DTI may rapidly evolve into a full-thickness wound. The
nurse must implement aggressive pressure redistribution, avoid massage over the area (which
can worsen deep tissue damage), and monitor closely for deterioration. DTI can be difficult to
stage initially because the full extent of tissue damage may not be visible for 24–72 hours.
Question 4 — Braden Scale Assessment (Select-All-That-Apply)
A nursing student is caring for a 70-year-old patient who scored 14 on the Braden Scale.
Which nursing interventions are appropriate based on this score? (Select all that apply.)
A. Reposition the patient every 2 hours while in bed [CORRECT]
B. Place the patient on a pressure-redistributing mattress [CORRECT]
C. Implement a toileting schedule every 4 hours to address moisture risk [CORRECT]
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D. Encourage the patient to ambulate independently in the hallway three times daily
E. Assess nutritional intake and consult dietitian if intake is <50% of meals [CORRECT]
F. Document that the patient is at low risk for pressure injury development
Rationale: A Braden Scale score of ≤18 indicates risk for pressure injury development; a score
of 14 indicates moderate risk. The Braden Scale evaluates six categories: Sensory Perception,
Moisture, Activity, Mobility, Nutrition, and Friction/Shear. Appropriate interventions include:
repositioning every 2 hours (minimum standard for at-risk patients), pressure-redistributing
surfaces, moisture management with scheduled toileting, nutritional assessment and
optimization, and minimizing friction/shear during repositioning. Independent ambulation is
not appropriate without first assessing the patient's mobility status and fall risk. The nurse
must document that the patient is at moderate risk, not low risk.
Question 5 — Braden Scale Risk Factors (Multiple-Choice)
A nurse is admitting an 82-year-old patient with a history of stroke, urinary incontinence, and
poor oral intake. The patient is bedbound and requires two staff members for repositioning.
Which Braden Scale category is most likely to place this patient at highest risk for pressure
injury development?
A. Sensory perception
B. Moisture
C. Activity
D. Friction and shear [CORRECT]
Rationale: Friction and shear is the Braden Scale category most likely to score lowest (1 = very
high risk) in this patient. The patient requires two staff members for repositioning, indicating
significant assistance is needed and the patient likely slides against the sheets during
transfers, creating shear forces. Shear is particularly damaging because it displaces tissue
layers and compromises blood supply to deep tissues. While moisture (from incontinence),
activity (bedbound), and sensory perception (post-stroke) all contribute to risk, friction and
shear cause the most rapid and severe tissue damage. The nurse must use a draw sheet, lift
rather than drag, and maintain the head of bed at ≤30 degrees when possible to minimize
shear.
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Question 6 — Bathing and Oral Hygiene (Multiple-Choice)
A nurse is providing a complete bed bath to a patient with a central line and a Stage 2
pressure injury on the coccyx. Which action demonstrates correct aseptic technique?
A. Bathing from the cleanest area to the dirtiest area, then changing bath water before
washing the perineum
B. Washing the face first, then the arms, then the perineum, then the wound area last with
clean gloves and sterile saline [CORRECT]
C. Using the same washcloth for the face and the perineum to conserve supplies
D. Cleaning the wound first with the bath water, then proceeding with the rest of the bath
Rationale: The correct sequence for a complete bed bath is cleanest to dirtiest: face, arms,
chest, abdomen, legs, back, perineum, and finally any open wounds. The wound should be
cleaned last using clean gloves and sterile saline (or prescribed wound cleanser) to prevent
cross-contamination. The face and perineum must never share the same washcloth. Bath
water should be changed if it becomes cool or soiled. For patients with central lines, the nurse
must avoid submerging the line or dressing and must maintain sterile technique when
accessing the line.
Question 7 — Perineal Care (Select-All-That-Apply)
A nurse is providing perineal care to a female patient with a Foley catheter and mild perineal
erythema. Which actions demonstrate correct technique? (Select all that apply.)
A. Using a clean washcloth for each stroke and wiping from front to back [CORRECT]
B. Securing the catheter tubing to the patient's inner thigh to prevent tension on the urethra
[CORRECT]
C. Cleaning the urinary meatus and catheter insertion site with soap and water [CORRECT]
D. Applying an antibiotic ointment to the erythematous area without a provider order
E. Using a circular motion to clean the catheter from the meatus outward [CORRECT]
F. Assessing the skin for signs of candidiasis or contact dermatitis [CORRECT]
JOYCE UNIVERSITY | NURSING FUNDAMENTALS
(NUR125) EXAM 2 –| 2026/2027 QUESTION BANK
WITH VERIFIED SOLUTIONS.
Question 1 — Pressure Injury Staging (Multiple-Choice)
A 78-year-old patient with a history of heart failure is admitted after a fall. During skin
assessment, the nurse observes a 3 cm × 2 cm area of non-blanchable erythema over the
patient's right ischial tuberosity. The skin is intact with no blisters, open areas, or drainage.
How should the nurse document this finding?
A. Stage 2 pressure injury
B. Stage 1 pressure injury [CORRECT]
C. Deep Tissue Injury (DTI)
D. Unstageable pressure injury
Rationale: This is a Stage 1 pressure injury, defined as non-blanchable erythema of intact skin.
The key differentiators are: skin remains intact (rules out Stage 2), discoloration is superficial
erythema rather than deep red/maroon/purple (rules out DTI), and the wound bed is fully
visible without slough or eschar (rules out unstageable). In patients with darker skin tones,
the nurse should assess for changes in skin temperature, tissue consistency, and pain, as
erythema may be more difficult to visualize.
Question 2 — Pressure Injury Staging (Multiple-Choice)
During a wound assessment, the nurse observes a full-thickness wound over the sacrum with
visible yellow subcutaneous fat but no exposure of bone, tendon, or muscle. Slough is present
but does not obscure the wound bed. What is the correct staging?
A. Stage 2 pressure injury
B. Stage 3 pressure injury [CORRECT]
C. Stage 4 pressure injury
D. Unstageable pressure injury
, 2
Rationale: This is a Stage 3 pressure injury, defined as full-thickness skin loss in which adipose
tissue (fat) is visible in the ulcer. The wound bed may contain slough, but slough does not
obscure the depth—allowing the nurse to confirm that bone, tendon, and muscle are not
exposed (which would indicate Stage 4). Tunneling or undermining may be present but does
not change the stage. The nurse must document the presence of slough and measure
undermining/tunneling for treatment planning.
Question 3 — Deep Tissue Injury (Multiple-Choice)
A 62-year-old patient with diabetes and peripheral vascular disease is transferred from a long-
term care facility. The nurse notes a 4 cm × 3 cm area of persistent deep maroon discoloration
on the left heel. The skin is intact but feels boggy and warmer than surrounding tissue. The
patient reports significant pain at the site. What is the priority nursing diagnosis?
A. Risk for infection related to open wound
B. Acute pain related to Stage 2 pressure injury
C. Risk for impaired skin integrity related to Deep Tissue Injury [CORRECT]
D. Ineffective tissue perfusion related to arterial insufficiency
Rationale: This is a Deep Tissue Injury (DTI), characterized by persistent non-blanchable deep
red, maroon, or purple discoloration of intact or non-intact skin. The boggy consistency and
pain are hallmark signs of underlying tissue damage. The priority nursing diagnosis is Risk for
impaired skin integrity because the DTI may rapidly evolve into a full-thickness wound. The
nurse must implement aggressive pressure redistribution, avoid massage over the area (which
can worsen deep tissue damage), and monitor closely for deterioration. DTI can be difficult to
stage initially because the full extent of tissue damage may not be visible for 24–72 hours.
Question 4 — Braden Scale Assessment (Select-All-That-Apply)
A nursing student is caring for a 70-year-old patient who scored 14 on the Braden Scale.
Which nursing interventions are appropriate based on this score? (Select all that apply.)
A. Reposition the patient every 2 hours while in bed [CORRECT]
B. Place the patient on a pressure-redistributing mattress [CORRECT]
C. Implement a toileting schedule every 4 hours to address moisture risk [CORRECT]
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D. Encourage the patient to ambulate independently in the hallway three times daily
E. Assess nutritional intake and consult dietitian if intake is <50% of meals [CORRECT]
F. Document that the patient is at low risk for pressure injury development
Rationale: A Braden Scale score of ≤18 indicates risk for pressure injury development; a score
of 14 indicates moderate risk. The Braden Scale evaluates six categories: Sensory Perception,
Moisture, Activity, Mobility, Nutrition, and Friction/Shear. Appropriate interventions include:
repositioning every 2 hours (minimum standard for at-risk patients), pressure-redistributing
surfaces, moisture management with scheduled toileting, nutritional assessment and
optimization, and minimizing friction/shear during repositioning. Independent ambulation is
not appropriate without first assessing the patient's mobility status and fall risk. The nurse
must document that the patient is at moderate risk, not low risk.
Question 5 — Braden Scale Risk Factors (Multiple-Choice)
A nurse is admitting an 82-year-old patient with a history of stroke, urinary incontinence, and
poor oral intake. The patient is bedbound and requires two staff members for repositioning.
Which Braden Scale category is most likely to place this patient at highest risk for pressure
injury development?
A. Sensory perception
B. Moisture
C. Activity
D. Friction and shear [CORRECT]
Rationale: Friction and shear is the Braden Scale category most likely to score lowest (1 = very
high risk) in this patient. The patient requires two staff members for repositioning, indicating
significant assistance is needed and the patient likely slides against the sheets during
transfers, creating shear forces. Shear is particularly damaging because it displaces tissue
layers and compromises blood supply to deep tissues. While moisture (from incontinence),
activity (bedbound), and sensory perception (post-stroke) all contribute to risk, friction and
shear cause the most rapid and severe tissue damage. The nurse must use a draw sheet, lift
rather than drag, and maintain the head of bed at ≤30 degrees when possible to minimize
shear.
, 4
Question 6 — Bathing and Oral Hygiene (Multiple-Choice)
A nurse is providing a complete bed bath to a patient with a central line and a Stage 2
pressure injury on the coccyx. Which action demonstrates correct aseptic technique?
A. Bathing from the cleanest area to the dirtiest area, then changing bath water before
washing the perineum
B. Washing the face first, then the arms, then the perineum, then the wound area last with
clean gloves and sterile saline [CORRECT]
C. Using the same washcloth for the face and the perineum to conserve supplies
D. Cleaning the wound first with the bath water, then proceeding with the rest of the bath
Rationale: The correct sequence for a complete bed bath is cleanest to dirtiest: face, arms,
chest, abdomen, legs, back, perineum, and finally any open wounds. The wound should be
cleaned last using clean gloves and sterile saline (or prescribed wound cleanser) to prevent
cross-contamination. The face and perineum must never share the same washcloth. Bath
water should be changed if it becomes cool or soiled. For patients with central lines, the nurse
must avoid submerging the line or dressing and must maintain sterile technique when
accessing the line.
Question 7 — Perineal Care (Select-All-That-Apply)
A nurse is providing perineal care to a female patient with a Foley catheter and mild perineal
erythema. Which actions demonstrate correct technique? (Select all that apply.)
A. Using a clean washcloth for each stroke and wiping from front to back [CORRECT]
B. Securing the catheter tubing to the patient's inner thigh to prevent tension on the urethra
[CORRECT]
C. Cleaning the urinary meatus and catheter insertion site with soap and water [CORRECT]
D. Applying an antibiotic ointment to the erythematous area without a provider order
E. Using a circular motion to clean the catheter from the meatus outward [CORRECT]
F. Assessing the skin for signs of candidiasis or contact dermatitis [CORRECT]
