lOMoARcPSD| 57911371
FUNDAMENTALS OF NURSING EXAM PRACTICE
TEST ACTUAL QUESTIONS AND ANSWERS LATEST
UPDATED AND VERIFIED SOLUTIONS
1. The nurse is working on a medical-surgical unit that has been participating in a
research project associated with pressure ulcers. The nurse recognizes that the risk
factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain. - ANS: B
Patients who are confused or disoriented or who have changing levels of
consciousness are unable to protect themselves. The patient may feel the pressure but
, lOMoARcPSD| 57911371
may not understand what to do to relieve the discomfort or to communicate that he or
she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction,
and moisture are other predisposing factors. Shortness of breath, muscular pain, and a
diet low in calories and fat are not included among the predisposing factors.
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks
ago. The patient sustained a head injury and is unconscious. The nurse is able to
identify that the major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight. - ANS: A
Pressure is the main element that causes pressure ulcers. Three pressure-related
factors contribute to pressure ulcer development: pressure intensity, pressure duration,
and tissue tolerance. When the intensity of the pressure exerted on the capillary
exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the
tissues it normally feeds. High pressure over a short time and low pressure over a long
time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging
effect of something), stress (worry or anxiety), and weight (individuals of all sizes,
shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.
3. Which nursing observation would indicate that the patient was at risk for pressure
ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds. - ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation
by making it susceptible to injury. Moisture can originate from wound drainage,
excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the
stool can enhance the opportunity for skin breakdown because the skin is moistened
and softened, causing maceration. Eating a balanced diet is important for nutrition, but
eating just two thirds of the meal does not indicate that the individual is at risk. A raised
red rash on the leg again is a concern and can affect the integrity of the skin, but it is
located on the shin, which is not a high-risk area for skin breakdown. Pressure can
influence capillary refill, leading to skin breakdown, but this capillary response is within
normal limits.
2 CHAPTER 1
)
, lOMoARcPSD| 57911371
4. The wound care nurse visits a patient in the long-term care unit. The nurse is
monitoring a patient with a stage III pressure ulcer. The wound seems to be healing,
and healthy tissue is observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer - ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the
same stage and is labeled with the words "healing stage." Once an ulcer has been
staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it
cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no
longer labeled a stage III.
5. The nurse is admitting an older patient from a nursing home. During the assessment,
the nurse notes a shallow open ulcer without slough on the right heel of the patient. This
pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV. - ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin
loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically
as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable
redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may
be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-
thickness tissue loss with exposed bone, tendon, or muscle.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin.
Which of the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light - ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to
accurately complete the first step in assessment—inspection—and the whole
assessment process. Natural light or a halogen light is recommended. Fluorescent light
sources can produce blue tones on darkly pigmented skin and can interfere with an
accurate assessment. Other items that could possibly be used during the assessment
include gloves for infection control, a disposable measuring device to measure the size
of the wound, and a cotton-tipped applicator to measure the depth of the wound, but
these items not the first item used.
7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that
a pressure ulcer takes time to heal and is an example of
FUNDAMENTALS OF NURSING EXAM PRACTICE
TEST ACTUAL QUESTIONS AND ANSWERS LATEST
UPDATED AND VERIFIED SOLUTIONS
1. The nurse is working on a medical-surgical unit that has been participating in a
research project associated with pressure ulcers. The nurse recognizes that the risk
factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain. - ANS: B
Patients who are confused or disoriented or who have changing levels of
consciousness are unable to protect themselves. The patient may feel the pressure but
, lOMoARcPSD| 57911371
may not understand what to do to relieve the discomfort or to communicate that he or
she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction,
and moisture are other predisposing factors. Shortness of breath, muscular pain, and a
diet low in calories and fat are not included among the predisposing factors.
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks
ago. The patient sustained a head injury and is unconscious. The nurse is able to
identify that the major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight. - ANS: A
Pressure is the main element that causes pressure ulcers. Three pressure-related
factors contribute to pressure ulcer development: pressure intensity, pressure duration,
and tissue tolerance. When the intensity of the pressure exerted on the capillary
exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the
tissues it normally feeds. High pressure over a short time and low pressure over a long
time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging
effect of something), stress (worry or anxiety), and weight (individuals of all sizes,
shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.
3. Which nursing observation would indicate that the patient was at risk for pressure
ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds. - ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation
by making it susceptible to injury. Moisture can originate from wound drainage,
excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the
stool can enhance the opportunity for skin breakdown because the skin is moistened
and softened, causing maceration. Eating a balanced diet is important for nutrition, but
eating just two thirds of the meal does not indicate that the individual is at risk. A raised
red rash on the leg again is a concern and can affect the integrity of the skin, but it is
located on the shin, which is not a high-risk area for skin breakdown. Pressure can
influence capillary refill, leading to skin breakdown, but this capillary response is within
normal limits.
2 CHAPTER 1
)
, lOMoARcPSD| 57911371
4. The wound care nurse visits a patient in the long-term care unit. The nurse is
monitoring a patient with a stage III pressure ulcer. The wound seems to be healing,
and healthy tissue is observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer - ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the
same stage and is labeled with the words "healing stage." Once an ulcer has been
staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it
cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no
longer labeled a stage III.
5. The nurse is admitting an older patient from a nursing home. During the assessment,
the nurse notes a shallow open ulcer without slough on the right heel of the patient. This
pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV. - ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin
loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically
as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable
redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may
be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-
thickness tissue loss with exposed bone, tendon, or muscle.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin.
Which of the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light - ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to
accurately complete the first step in assessment—inspection—and the whole
assessment process. Natural light or a halogen light is recommended. Fluorescent light
sources can produce blue tones on darkly pigmented skin and can interfere with an
accurate assessment. Other items that could possibly be used during the assessment
include gloves for infection control, a disposable measuring device to measure the size
of the wound, and a cotton-tipped applicator to measure the depth of the wound, but
these items not the first item used.
7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that
a pressure ulcer takes time to heal and is an example of
