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A nurse is assessing a patient with a stage I pressure injury. Which finding is expected?
A. Full-thickness skin loss
B. Non-blanchable erythema
C. Exposed bone
D. Slough present
Answer: B. Non-blanchable erythema
Rationale: Stage I pressure injuries present as intact skin with non-blanchable redness.
There is no open wound or tissue loss at this stage.
A patient with a stage III pressure ulcer would exhibit which characteristic?
A. Partial-thickness skin loss
B. Intact skin with redness
C. Full-thickness tissue loss without exposed bone
D. Exposed tendon and bone
Answer: C. Full-thickness tissue loss without exposed bone
Rationale: Stage III ulcers involve full-thickness skin loss but do not expose bone,
tendon, or muscle.
Which intervention is most appropriate to prevent pressure injuries in an immobile
patient?
A. Limit fluid intake
B. Reposition every 2 hours
,C. Massage bony prominences
D. Keep head elevated at all times
Answer: B. Reposition every 2 hours
Rationale: Frequent repositioning reduces prolonged pressure, which is the primary
cause of pressure injuries.
A nurse notes slough in a wound bed. What does this indicate?
A. Healthy granulation
B. Necrotic tissue
C. Epithelialization
D. Infection-free healing
Answer: B. Necrotic tissue
Rationale: Slough is yellow or tan necrotic tissue that must often be removed for proper
healing.
Which dressing is most appropriate for a heavily exudating wound?
A. Hydrocolloid
B. Transparent film
C. Alginate
D. Dry gauze
Answer: C. Alginate
Rationale: Alginate dressings are highly absorbent and ideal for wounds with heavy
drainage.
A nurse is caring for a burn patient. Which finding indicates a superficial (first-degree)
burn?
A. Blistering
B. Charred skin
C. Redness and pain
D. White leathery skin
,Answer: C. Redness and pain
Rationale: First-degree burns affect only the epidermis and present with redness and
pain without blisters.
Which phase of wound healing involves collagen formation?
A. Hemostasis
B. Inflammatory
C. Proliferative
D. Maturation
Answer: C. Proliferative
Rationale: During the proliferative phase, fibroblasts produce collagen and granulation
tissue forms.
A nurse identifies purulent drainage from a wound. What does this suggest?
A. Normal healing
B. Infection
C. Dehydration
D. Epithelialization
Answer: B. Infection
Rationale: Purulent drainage is thick, often yellow/green, and indicates infection.
Which nutrient is most important for wound healing?
A. Vitamin C
B. Sodium
C. Potassium
D. Vitamin D
Answer: A. Vitamin C
Rationale: Vitamin C supports collagen synthesis and immune function, critical for
healing.
, A patient has a wound with tunneling. What does this mean?
A. Surface-level damage
B. Deep channels into tissue
C. Only epidermal involvement
D. Scar tissue formation
Answer: B. Deep channels into tissue
Rationale: Tunneling refers to narrow passageways extending from the wound into
deeper tissues.
Which action should the nurse avoid when caring for fragile skin?
A. Using paper tape
B. Gentle handling
C. Adhesive removal carefully
D. Rubbing vigorously
Answer: D. Rubbing vigorously
Rationale: Fragile skin can easily tear; vigorous rubbing increases risk of injury.
A Braden Scale score of 10 indicates what risk level?
A. Low
B. Moderate
C. High
D. No risk
Answer: C. High
Rationale: Lower Braden scores indicate higher risk; a score of 10 reflects high risk.
Which sign indicates wound dehiscence?
A. Increased drainage
B. Wound edges separating
C. Redness