NSG300 EXAM 2 QUESTIONS AND ANSWERS
What are 3 pressure related factors that contribute to pressure ulcer development? - CORRECT
ANSWER✅✅1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - CORRECT ANSWER✅✅If pressure applied over a capillary
exceeds normal capillary pressure and the vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - CORRECT ANSWER✅✅tissue death
Does blanching occur in dark skinned patients? - CORRECT ANSWER✅✅No, blanching does not occur
but color, texture and temp may differ from surrounding area
What does pressure duration assess? - CORRECT 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 is tissue tolerance? - CORRECT 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? - CORRECT ANSWER✅✅◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
,What should the nurse look for when assessing a pressure injury? - CORRECT 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 - CORRECT ANSWER✅✅Intact skin with nonblanchable redness
stage 2 pressure injury - CORRECT ANSWER✅✅partial thickness skin loss involving epidermis, dermis or
both and, shallow abrasion or open blister looking
stage 3 pressure injury - CORRECT ANSWER✅✅full thickness skin loss extending to SQ, crater looking
stage 4 pressure injury - CORRECT ANSWER✅✅full thickness with exposed bone, muscle or tendon and
may have eschar
What characteristics does stage 3 and 4 pressure injuries share? - CORRECT 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? - CORRECT 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? - CORRECT ANSWER✅✅brown or black necrotic tissue
Unstageable/Unclassified Pressure Ulcer - CORRECT ANSWER✅✅Tissue loss but depth unknown
because wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and states "it will heal on its own".
What education should the nurse provide? - CORRECT ANSWER✅✅Slough and eschar must be removed
by a clinician to determine the stage and in order for healing to occur
, suspected deep tissue injury - CORRECT 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
A nurse is assessing a wound and notes the presence of granulation tissue. What should the student
nurse expect to see? - CORRECT ANSWER✅✅Red, moist tissue which indicates progression toward
healing
What should the nurse document when assessing exudate? - CORRECT ANSWER✅✅Amount, color,
consistency and odor
The student nurse sees an excess amount of exudate in the wound bed. What does this indicate? -
CORRECT ANSWER✅✅The presence of infection
What should the nurse look for when assessing the periwound area? Why is it important? - CORRECT
ANSWER✅✅Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
Why is wound classification important? - CORRECT ANSWER✅✅Allows a nurse to understand the risks
associated with a wound and implications for healing
How does a partial thickness wound heal? - CORRECT ANSWER✅✅Heals by regeneration
How does a full thickness would heal? - CORRECT ANSWER✅✅Heals by forming new tissue which takes
longer
What are the three components involved in the healing process of a partial thickness wound? - CORRECT
ANSWER✅✅Inflammatory response, epithelial proliferation and migration, and reestablishment of
epidermal layers
A patient states keeping his wound exposed to air while allow his wound to heal quickly. What
education should the nurse provide to the patient? - CORRECT ANSWER✅✅Wounds heal faster in moist
environments because epidermal cells only migrate across moist surfaces.
What are 3 pressure related factors that contribute to pressure ulcer development? - CORRECT
ANSWER✅✅1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - CORRECT ANSWER✅✅If pressure applied over a capillary
exceeds normal capillary pressure and the vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - CORRECT ANSWER✅✅tissue death
Does blanching occur in dark skinned patients? - CORRECT ANSWER✅✅No, blanching does not occur
but color, texture and temp may differ from surrounding area
What does pressure duration assess? - CORRECT 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 is tissue tolerance? - CORRECT 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? - CORRECT ANSWER✅✅◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
,What should the nurse look for when assessing a pressure injury? - CORRECT 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 - CORRECT ANSWER✅✅Intact skin with nonblanchable redness
stage 2 pressure injury - CORRECT ANSWER✅✅partial thickness skin loss involving epidermis, dermis or
both and, shallow abrasion or open blister looking
stage 3 pressure injury - CORRECT ANSWER✅✅full thickness skin loss extending to SQ, crater looking
stage 4 pressure injury - CORRECT ANSWER✅✅full thickness with exposed bone, muscle or tendon and
may have eschar
What characteristics does stage 3 and 4 pressure injuries share? - CORRECT 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? - CORRECT 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? - CORRECT ANSWER✅✅brown or black necrotic tissue
Unstageable/Unclassified Pressure Ulcer - CORRECT ANSWER✅✅Tissue loss but depth unknown
because wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and states "it will heal on its own".
What education should the nurse provide? - CORRECT ANSWER✅✅Slough and eschar must be removed
by a clinician to determine the stage and in order for healing to occur
, suspected deep tissue injury - CORRECT 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
A nurse is assessing a wound and notes the presence of granulation tissue. What should the student
nurse expect to see? - CORRECT ANSWER✅✅Red, moist tissue which indicates progression toward
healing
What should the nurse document when assessing exudate? - CORRECT ANSWER✅✅Amount, color,
consistency and odor
The student nurse sees an excess amount of exudate in the wound bed. What does this indicate? -
CORRECT ANSWER✅✅The presence of infection
What should the nurse look for when assessing the periwound area? Why is it important? - CORRECT
ANSWER✅✅Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
Why is wound classification important? - CORRECT ANSWER✅✅Allows a nurse to understand the risks
associated with a wound and implications for healing
How does a partial thickness wound heal? - CORRECT ANSWER✅✅Heals by regeneration
How does a full thickness would heal? - CORRECT ANSWER✅✅Heals by forming new tissue which takes
longer
What are the three components involved in the healing process of a partial thickness wound? - CORRECT
ANSWER✅✅Inflammatory response, epithelial proliferation and migration, and reestablishment of
epidermal layers
A patient states keeping his wound exposed to air while allow his wound to heal quickly. What
education should the nurse provide to the patient? - CORRECT ANSWER✅✅Wounds heal faster in moist
environments because epidermal cells only migrate across moist surfaces.
