NCLEX RN Pressure Ulcers Exam 2024 Actual
Exam Questions And Correct Detailed Answers
Complete Solution
1. You are assigned four patients on your nursing unit. Which patient is at most risk for
pressure ulcers?
A) A 72 year old female weighing 82lbs with stress incontinence and dementia.
B) A 90 year old male with Congestive Heart Failure who has 3+ pitting edema in lower
extremities.
C) A 6 month old with the flu.
D) An ambulatory 88 year old with dementia who is admitted with shingles. - Answer-A)
A 72 year old female weighing 82lbs with stress incontinence and dementia.
2. A home health nurse knows that a 70-year-old male client who is convalescing at
home following a hip replacement is at risk for developing pressure ulcers. Which
physical characteristic of aging puts the client at greatest risk?
A. 16% increase in overall body fat
B. Reduced melanin production
C. Thinning of the skin, with loss of elasticity
D. Calcium loss in the bones - Answer-C. Thinning of the skin, with loss of elasticity
3. As a home care nurse, you are providing care to a 63 year old male who suffered a
massive stroke. He has paralysis on upper and lower extremities. He has a PEG tube
with tubing feedings. The patient's daughter provides care to the patient. You notice the
patient has a stage I pressure ulcer on the sacral area. What would you NOT include
when educating the daughter on preventing further breakdown of the current pressure
ulcer and how to prevent other ones from forming?
A. Exercise the extremities actively and passively.
B. Turn and reposition the patient every 2 hours.
C. Keep the skin moist and layer the sacral area with extra sheet layers.
D. Use pillows to elevated bony prominences. - Answer-C. Keep the skin moist and
layer the sacral area with extra sheet layers.
, 4. The home health registered nurse is reinforcing instructions to the family about how
to prevent pressure ulcers for their family member who is bedridden. Which measure
should the RN discuss?
A) Lift the client when turning to prevent sliding
B) Massage directly over reddened sites
C) Change client's position every 4 hours
D) Place pillows under both knees - Answer-A) Lift the client when turning to prevent
sliding
5. A nurse is using the Braden scale to assess a patient's risk for pressure ulcer
formation. Upon assessment, the patient's sensory perception appears to be slightly
limited, is occasionally moist, mobility is slightly limited, and walks occasionally.
Nutrition is adequate and friction is a potential problem. What is this patient's risk?
A) High
B) Very High
C) Mild
D) Moderate - Answer-C) Mild
6. The home health RN is assessing an older client for a pressure ulcer. Which finding
should the RN observe the area for a Stage 1 pressure ulcer?
A) Superficial skin breakdown and flaking
B) Deep, pink, red, or mottled skin
C) Subcutaneous damage or necrosis
D) Skin that blanches pink when pressed - Answer-B) Deep, pink, red, or mottled skin
7. The RN is assessing the skin of an older client. Which finding should the nurse
document as consistent with the normal aging process?
A) Decreased elasticity
B) Tough and leathery texture
C) Shiny and edematous
Exam Questions And Correct Detailed Answers
Complete Solution
1. You are assigned four patients on your nursing unit. Which patient is at most risk for
pressure ulcers?
A) A 72 year old female weighing 82lbs with stress incontinence and dementia.
B) A 90 year old male with Congestive Heart Failure who has 3+ pitting edema in lower
extremities.
C) A 6 month old with the flu.
D) An ambulatory 88 year old with dementia who is admitted with shingles. - Answer-A)
A 72 year old female weighing 82lbs with stress incontinence and dementia.
2. A home health nurse knows that a 70-year-old male client who is convalescing at
home following a hip replacement is at risk for developing pressure ulcers. Which
physical characteristic of aging puts the client at greatest risk?
A. 16% increase in overall body fat
B. Reduced melanin production
C. Thinning of the skin, with loss of elasticity
D. Calcium loss in the bones - Answer-C. Thinning of the skin, with loss of elasticity
3. As a home care nurse, you are providing care to a 63 year old male who suffered a
massive stroke. He has paralysis on upper and lower extremities. He has a PEG tube
with tubing feedings. The patient's daughter provides care to the patient. You notice the
patient has a stage I pressure ulcer on the sacral area. What would you NOT include
when educating the daughter on preventing further breakdown of the current pressure
ulcer and how to prevent other ones from forming?
A. Exercise the extremities actively and passively.
B. Turn and reposition the patient every 2 hours.
C. Keep the skin moist and layer the sacral area with extra sheet layers.
D. Use pillows to elevated bony prominences. - Answer-C. Keep the skin moist and
layer the sacral area with extra sheet layers.
, 4. The home health registered nurse is reinforcing instructions to the family about how
to prevent pressure ulcers for their family member who is bedridden. Which measure
should the RN discuss?
A) Lift the client when turning to prevent sliding
B) Massage directly over reddened sites
C) Change client's position every 4 hours
D) Place pillows under both knees - Answer-A) Lift the client when turning to prevent
sliding
5. A nurse is using the Braden scale to assess a patient's risk for pressure ulcer
formation. Upon assessment, the patient's sensory perception appears to be slightly
limited, is occasionally moist, mobility is slightly limited, and walks occasionally.
Nutrition is adequate and friction is a potential problem. What is this patient's risk?
A) High
B) Very High
C) Mild
D) Moderate - Answer-C) Mild
6. The home health RN is assessing an older client for a pressure ulcer. Which finding
should the RN observe the area for a Stage 1 pressure ulcer?
A) Superficial skin breakdown and flaking
B) Deep, pink, red, or mottled skin
C) Subcutaneous damage or necrosis
D) Skin that blanches pink when pressed - Answer-B) Deep, pink, red, or mottled skin
7. The RN is assessing the skin of an older client. Which finding should the nurse
document as consistent with the normal aging process?
A) Decreased elasticity
B) Tough and leathery texture
C) Shiny and edematous
