4 M A X E • S L AT N E M A D N U F
★ ★
Nursing Fundamentals Assessment
N Comprehensive Examination — Exam 4
EST. 2026
E XC E L L E N C E I N N U RS I N G E D U C AT I O N
Nursing Fundamentals — Exam 4
W O U N D C A R E , S T R O K E , S K I N D I S O R D E R S , C A R D I A C & H E M O D Y N A M I CS
INSTITUTION Nursing Fundamentals Assessment COURSE CODE Nursing Fundamentals — Exam 4
PROGRAM Practical Nursing (PN) / Associate Degree ACADEMIC YEAR
in Nursing (ADN)
EXAM TITLE Nursing Fundamentals Exam 4 TOTAL QUESTIONS 50 Questions
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions are indicated — choose every correct option.
▸ Questions cover wound care, stroke, skin disorders, cardiac function, and hemodynamics.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All content reflects current evidence-based nursing practice.
SECTION I — FUNDAMENTALS OF NURSING COMPREHENSIVE Questions 1 –
EXAMINATION 50
1. A surgical incision heals with well-approximated edges and minimal scarring. This is which type of wound healing
intention?
A. Primary intention.
B. Secondary intention.
C. Tertiary intention.
D. Regenerative intention.
CORRECT ANSWER A — Primary intention.
RATIONALE Primary intention (first intention) healing occurs when a clean surgical wound is closed immediately with
sutures, staples, or adhesive. The wound edges are well-approximated, there is minimal tissue loss, and
healing proceeds rapidly with minimal granulation tissue and minimal scarring. Examples: planned surgical
incisions, clean lacerations that are sutured. Secondary intention (B) occurs with extensive tissue loss where
edges cannot be approximated — the wound heals from the bottom up (burns, Stage 2–4 pressure injuries,
severe lacerations). Tertiary intention (C) involves contaminated wounds or abdominal incisions with
complicated infections — the wound is left open initially, then closed surgically after infection resolves. The
healing intention guides wound management, expected healing time, and patient education.
,2. A burn wound heals from the bottom up with extensive granulation tissue formation and significant scarring. This
is which type of wound healing intention?
A. Primary intention.
B. Secondary intention.
C. Tertiary intention.
D. Delayed primary closure.
CORRECT ANSWER B — Secondary intention.
RATIONALE Secondary intention healing occurs when there is extensive tissue loss and wound edges cannot be
approximated. The wound heals from the bottom up through granulation tissue formation, wound
contraction, and epithelialization — this process is slower and results in more scarring. Examples: burns,
Stage 2–4 pressure injuries, severe lacerations, dehisced surgical wounds. The wound is left open and fills
with granulation tissue from the base upward. Key differences from primary intention: longer healing time,
greater susceptibility to infection, and more significant scar formation. Nursing care focuses on: preventing
infection, maintaining a moist wound environment, protecting granulation tissue, managing exudate, and
supporting nutrition for healing. Wounds healing by secondary intention require ongoing assessment and
appropriate dressing selection.
3. What are the four phases of full-thickness wound repair in correct order?
A. Inflammatory response → Hemostasis → Proliferation → Remodeling.
B. Hemostasis → Inflammatory response → Proliferation and new tissue formation → Remodeling and maturation.
C. Proliferation → Hemostasis → Remodeling → Inflammatory response.
D. Remodeling → Proliferation → Inflammatory response → Hemostasis.
CORRECT ANSWER B — Hemostasis → Inflammatory response → Proliferation and new tissue formation → Remodeling
and maturation.
RATIONALE Full-thickness wound repair occurs in four overlapping phases: (1) Hemostasis — immediately after injury;
vasoconstriction, platelet aggregation, fibrin clot formation. (2) Inflammatory response — lasts 3–6 days;
vasodilation, phagocytosis by macrophages and neutrophils to remove debris and bacteria. (3) Proliferation
and new tissue formation — days 3–21; collagen synthesis by fibroblasts, angiogenesis (new blood vessel
formation), granulation tissue formation, wound contraction, and epithelialization. (4) Remodeling and
maturation — day 21 through 1–2 years; collagen reorganization, scar strengthening, and flattening. Partial-
thickness wound repair follows: (1) Inflammatory response, (2) Epithelial proliferation and migration, (3)
Reestablishment of normal skin layers. Understanding these phases guides wound care at each stage —
protecting during proliferation, supporting during remodeling.
4. The nurse notes bright red wound drainage that indicates active bleeding. This is documented as:
A. Serous drainage.
B. Purulent drainage.
C. Serosanguineous drainage.
D. Sanguineous drainage.
CORRECT ANSWER D — Sanguineous drainage.
RATIONALE Sanguineous drainage is bright red and indicates active bleeding — it consists of fresh blood from damaged
capillaries or blood vessels. It is common immediately after injury or surgery. Darker red drainage indicates
older blood. Serous drainage (A) is clear, watery plasma — normal in healing wounds and blisters. Purulent
drainage (B) is thick, yellow/green/tan/brown — indicates infection (contains leukocytes, bacteria, and
cellular debris). Serosanguineous drainage (C) is pale pink, watery — a mixture of clear serous fluid and blood;
common in early healing. The TACO acronym guides drainage assessment: Type, Amount, Color, Odor. All
drainage characteristics must be documented at each dressing change. Changes in drainage type or amount
should be reported to the provider. A sudden increase in sanguineous drainage may indicate hemorrhage.
, 5. A Jackson-Pratt drain uses which mechanism to remove fluid from a wound?
A. Gravity drainage.
B. Suction — a compressed bulb creates negative pressure to draw fluid out.
C. Capillary action.
D. Passive wicking.
CORRECT ANSWER B — Suction — a compressed bulb creates negative pressure to draw fluid out.
RATIONALE A Jackson-Pratt (JP) drain is a closed-suction drainage system. It consists of a thin, flexible perforated tube
connected to a compressible bulb reservoir. When the bulb is compressed and the cap is closed, gentle
negative pressure (suction) draws fluid from the wound into the bulb. As the bulb fills with drainage and air,
suction decreases — the nurse must empty the drain, re-compress the bulb, and re-cap it to re-establish
suction. The drain is typically emptied every 4–8 hours and when half full. Drainage amount, color, and
consistency must be documented. A Penrose drain (A) is a soft, flexible rubber tube that drains by gravity — it
is an open drain. A Hemovac drain is similar to a JP but uses a spring-loaded disc. Wound VAC therapy uses
more powerful negative pressure.
6. A post-operative patient's abdominal wound separates completely, and loops of bowel are visible protruding
through the incision. This complication is called:
A. Dehiscence.
B. Evisceration.
C. Hemorrhage.
D. Fistula formation.
CORRECT ANSWER B — Evisceration.
RATIONALE Evisceration is the complete separation of ALL wound layers with protrusion of internal organs (viscera)
through the wound opening — a surgical emergency. The nurse must NEVER attempt to reinsert the organs.
Immediate actions: (1) Cover the protruding organs with sterile dressings saturated in sterile normal saline to
prevent tissue desiccation. (2) Keep the patient on strict bed rest with knees slightly bent to reduce
abdominal tension. (3) Stay with the patient and monitor vital signs for shock. (4) Notify the surgical team
immediately and prepare the patient for emergency surgery. Dehiscence (A) is partial or complete separation
of wound edges WITHOUT organ protrusion — the patient may report feeling "something pop." Hemorrhage
(C) is excessive bleeding. A fistula (D) is an abnormal tract between two organs or to the skin. Evisceration
often follows dehiscence if not promptly addressed.
7. The nurse is performing wound irrigation. What is the correct technique?
A. Irrigate from the dirtiest area to the cleanest area to remove contaminants.
B. Use 30–60 mL of sterile saline with a blunt tip irrigating syringe, flowing from the cleanest to the dirtiest area.
C. Irrigate with tap water using a high-pressure stream.
D. Pour sterile saline directly from the bottle onto the wound.
CORRECT ANSWER B — Use 30–60 mL of sterile saline with a blunt tip irrigating syringe, flowing from the cleanest to the
dirtiest area.
RATIONALE Wound irrigation uses sterile normal saline (30–60 mL per irrigation) delivered through a blunt tip syringe
with gentle pressure. The flow should be from the CLEANEST area to the DIRTIEST area to prevent introducing
contaminants into clean tissue. Irrigation solution is good for up to 24 hours once opened — label the bottle
with the date and time opened. Key principles: use sterile technique, wear PPE (irrigation can splash), direct
the flow gently to avoid tissue damage, and ensure all irrigation solution is collected to prevent skin
maceration. Do NOT irrigate from dirty to clean (A) — this spreads contamination. Tap water (C) is not sterile
and is not standard for surgical or acute wounds. Pouring directly from the bottle (D) does not provide
adequate pressure to remove debris and is not precise. The wound should be cleansed before culturing and
before applying new dressings.
★ ★
Nursing Fundamentals Assessment
N Comprehensive Examination — Exam 4
EST. 2026
E XC E L L E N C E I N N U RS I N G E D U C AT I O N
Nursing Fundamentals — Exam 4
W O U N D C A R E , S T R O K E , S K I N D I S O R D E R S , C A R D I A C & H E M O D Y N A M I CS
INSTITUTION Nursing Fundamentals Assessment COURSE CODE Nursing Fundamentals — Exam 4
PROGRAM Practical Nursing (PN) / Associate Degree ACADEMIC YEAR
in Nursing (ADN)
EXAM TITLE Nursing Fundamentals Exam 4 TOTAL QUESTIONS 50 Questions
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions are indicated — choose every correct option.
▸ Questions cover wound care, stroke, skin disorders, cardiac function, and hemodynamics.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All content reflects current evidence-based nursing practice.
SECTION I — FUNDAMENTALS OF NURSING COMPREHENSIVE Questions 1 –
EXAMINATION 50
1. A surgical incision heals with well-approximated edges and minimal scarring. This is which type of wound healing
intention?
A. Primary intention.
B. Secondary intention.
C. Tertiary intention.
D. Regenerative intention.
CORRECT ANSWER A — Primary intention.
RATIONALE Primary intention (first intention) healing occurs when a clean surgical wound is closed immediately with
sutures, staples, or adhesive. The wound edges are well-approximated, there is minimal tissue loss, and
healing proceeds rapidly with minimal granulation tissue and minimal scarring. Examples: planned surgical
incisions, clean lacerations that are sutured. Secondary intention (B) occurs with extensive tissue loss where
edges cannot be approximated — the wound heals from the bottom up (burns, Stage 2–4 pressure injuries,
severe lacerations). Tertiary intention (C) involves contaminated wounds or abdominal incisions with
complicated infections — the wound is left open initially, then closed surgically after infection resolves. The
healing intention guides wound management, expected healing time, and patient education.
,2. A burn wound heals from the bottom up with extensive granulation tissue formation and significant scarring. This
is which type of wound healing intention?
A. Primary intention.
B. Secondary intention.
C. Tertiary intention.
D. Delayed primary closure.
CORRECT ANSWER B — Secondary intention.
RATIONALE Secondary intention healing occurs when there is extensive tissue loss and wound edges cannot be
approximated. The wound heals from the bottom up through granulation tissue formation, wound
contraction, and epithelialization — this process is slower and results in more scarring. Examples: burns,
Stage 2–4 pressure injuries, severe lacerations, dehisced surgical wounds. The wound is left open and fills
with granulation tissue from the base upward. Key differences from primary intention: longer healing time,
greater susceptibility to infection, and more significant scar formation. Nursing care focuses on: preventing
infection, maintaining a moist wound environment, protecting granulation tissue, managing exudate, and
supporting nutrition for healing. Wounds healing by secondary intention require ongoing assessment and
appropriate dressing selection.
3. What are the four phases of full-thickness wound repair in correct order?
A. Inflammatory response → Hemostasis → Proliferation → Remodeling.
B. Hemostasis → Inflammatory response → Proliferation and new tissue formation → Remodeling and maturation.
C. Proliferation → Hemostasis → Remodeling → Inflammatory response.
D. Remodeling → Proliferation → Inflammatory response → Hemostasis.
CORRECT ANSWER B — Hemostasis → Inflammatory response → Proliferation and new tissue formation → Remodeling
and maturation.
RATIONALE Full-thickness wound repair occurs in four overlapping phases: (1) Hemostasis — immediately after injury;
vasoconstriction, platelet aggregation, fibrin clot formation. (2) Inflammatory response — lasts 3–6 days;
vasodilation, phagocytosis by macrophages and neutrophils to remove debris and bacteria. (3) Proliferation
and new tissue formation — days 3–21; collagen synthesis by fibroblasts, angiogenesis (new blood vessel
formation), granulation tissue formation, wound contraction, and epithelialization. (4) Remodeling and
maturation — day 21 through 1–2 years; collagen reorganization, scar strengthening, and flattening. Partial-
thickness wound repair follows: (1) Inflammatory response, (2) Epithelial proliferation and migration, (3)
Reestablishment of normal skin layers. Understanding these phases guides wound care at each stage —
protecting during proliferation, supporting during remodeling.
4. The nurse notes bright red wound drainage that indicates active bleeding. This is documented as:
A. Serous drainage.
B. Purulent drainage.
C. Serosanguineous drainage.
D. Sanguineous drainage.
CORRECT ANSWER D — Sanguineous drainage.
RATIONALE Sanguineous drainage is bright red and indicates active bleeding — it consists of fresh blood from damaged
capillaries or blood vessels. It is common immediately after injury or surgery. Darker red drainage indicates
older blood. Serous drainage (A) is clear, watery plasma — normal in healing wounds and blisters. Purulent
drainage (B) is thick, yellow/green/tan/brown — indicates infection (contains leukocytes, bacteria, and
cellular debris). Serosanguineous drainage (C) is pale pink, watery — a mixture of clear serous fluid and blood;
common in early healing. The TACO acronym guides drainage assessment: Type, Amount, Color, Odor. All
drainage characteristics must be documented at each dressing change. Changes in drainage type or amount
should be reported to the provider. A sudden increase in sanguineous drainage may indicate hemorrhage.
, 5. A Jackson-Pratt drain uses which mechanism to remove fluid from a wound?
A. Gravity drainage.
B. Suction — a compressed bulb creates negative pressure to draw fluid out.
C. Capillary action.
D. Passive wicking.
CORRECT ANSWER B — Suction — a compressed bulb creates negative pressure to draw fluid out.
RATIONALE A Jackson-Pratt (JP) drain is a closed-suction drainage system. It consists of a thin, flexible perforated tube
connected to a compressible bulb reservoir. When the bulb is compressed and the cap is closed, gentle
negative pressure (suction) draws fluid from the wound into the bulb. As the bulb fills with drainage and air,
suction decreases — the nurse must empty the drain, re-compress the bulb, and re-cap it to re-establish
suction. The drain is typically emptied every 4–8 hours and when half full. Drainage amount, color, and
consistency must be documented. A Penrose drain (A) is a soft, flexible rubber tube that drains by gravity — it
is an open drain. A Hemovac drain is similar to a JP but uses a spring-loaded disc. Wound VAC therapy uses
more powerful negative pressure.
6. A post-operative patient's abdominal wound separates completely, and loops of bowel are visible protruding
through the incision. This complication is called:
A. Dehiscence.
B. Evisceration.
C. Hemorrhage.
D. Fistula formation.
CORRECT ANSWER B — Evisceration.
RATIONALE Evisceration is the complete separation of ALL wound layers with protrusion of internal organs (viscera)
through the wound opening — a surgical emergency. The nurse must NEVER attempt to reinsert the organs.
Immediate actions: (1) Cover the protruding organs with sterile dressings saturated in sterile normal saline to
prevent tissue desiccation. (2) Keep the patient on strict bed rest with knees slightly bent to reduce
abdominal tension. (3) Stay with the patient and monitor vital signs for shock. (4) Notify the surgical team
immediately and prepare the patient for emergency surgery. Dehiscence (A) is partial or complete separation
of wound edges WITHOUT organ protrusion — the patient may report feeling "something pop." Hemorrhage
(C) is excessive bleeding. A fistula (D) is an abnormal tract between two organs or to the skin. Evisceration
often follows dehiscence if not promptly addressed.
7. The nurse is performing wound irrigation. What is the correct technique?
A. Irrigate from the dirtiest area to the cleanest area to remove contaminants.
B. Use 30–60 mL of sterile saline with a blunt tip irrigating syringe, flowing from the cleanest to the dirtiest area.
C. Irrigate with tap water using a high-pressure stream.
D. Pour sterile saline directly from the bottle onto the wound.
CORRECT ANSWER B — Use 30–60 mL of sterile saline with a blunt tip irrigating syringe, flowing from the cleanest to the
dirtiest area.
RATIONALE Wound irrigation uses sterile normal saline (30–60 mL per irrigation) delivered through a blunt tip syringe
with gentle pressure. The flow should be from the CLEANEST area to the DIRTIEST area to prevent introducing
contaminants into clean tissue. Irrigation solution is good for up to 24 hours once opened — label the bottle
with the date and time opened. Key principles: use sterile technique, wear PPE (irrigation can splash), direct
the flow gently to avoid tissue damage, and ensure all irrigation solution is collected to prevent skin
maceration. Do NOT irrigate from dirty to clean (A) — this spreads contamination. Tap water (C) is not sterile
and is not standard for surgical or acute wounds. Pouring directly from the bottle (D) does not provide
adequate pressure to remove debris and is not precise. The wound should be cleansed before culturing and
before applying new dressings.
