PNR 106/PNR106 Exam 4 V1 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse identifies a pressure ulcer with partial-thickness loss of dermis presenting as a
shallow open ulcer with a red-pink wound bed. What stage is this pressure ulcer?
A. Stage I
B. Stage III
C. Stage II
D. Stage IV
Correct Answer: C
Expert Explanation: Stage II pressure ulcers involve partial-thickness loss of dermis and
present as shallow, open ulcers without slough. They can also manifest as intact or open
serum-filled blisters. Nurses must carefully assess the wound bed to ensure it is not a Stage
III or IV injury.
2. When a wound heals by primary intention, which of the following characteristics is
typically observed?
A. The wound is left open to heal by granulation.
B. The wound requires skin grafting to close the defect.
C. There is a high risk of infection and extensive tissue loss.
,D. The wound edges are well-approximated with minimal scarring.
Correct Answer: D
Expert Explanation: Primary intention healing occurs when wound edges are pulled
together and secured with sutures, staples, or adhesive. This process results in minimal
tissue loss and a very fine scar. It is the preferred method for clean surgical incisions
without significant contamination.
3. A nurse observes thick, yellow drainage on a patient’s surgical dressing. How should the
nurse document this type of exudate?
A. Serous
B. Sanguineous
C. Purulent
D. Serosanguineous
Correct Answer: C
Expert Explanation: Purulent drainage is thick and consists of white blood cells, dead
tissue, and bacteria, often appearing yellow, green, or brown. It is a significant indicator of
a localized infection in the wound site. Documentation must include the color, odor, and
consistency of this drainage for accurate clinical tracking.
4. Which nutrition component is most critical for a patient who is recovering from major
surgery and has multiple stage III pressure ulcers?
A. Vitamin K
, B. Carbohydrates
C. Fats
D. Protein
Correct Answer: D
Expert Explanation: Protein is essential for tissue repair, collagen synthesis, and immune
system function during the wound healing process. A deficiency in protein can lead to
delayed healing and increased risk of wound dehiscence. Nurses should collaborate with
dietitians to ensure patients receive adequate caloric and protein intake for recovery.
5. A patient is 5 days postoperative and reports a ‘popping’ sensation after coughing,
followed by a sudden increase in serosanguineous drainage. What should the nurse suspect?
A. Evisceration
B. Dehiscence
C. Internal hemorrhage
D. Normal healing progress
Correct Answer: B
Expert Explanation: Dehiscence is the partial or total separation of wound layers, often
occurring after sudden strain like coughing or sneezing. It is a serious complication that
requires immediate assessment of the wound and notification of the surgical team.
Serosanguineous fluid drainage is a classic early warning sign of this mechanical failure.
of Nursing Q&A with Rationale | Fortis
College
1. A nurse identifies a pressure ulcer with partial-thickness loss of dermis presenting as a
shallow open ulcer with a red-pink wound bed. What stage is this pressure ulcer?
A. Stage I
B. Stage III
C. Stage II
D. Stage IV
Correct Answer: C
Expert Explanation: Stage II pressure ulcers involve partial-thickness loss of dermis and
present as shallow, open ulcers without slough. They can also manifest as intact or open
serum-filled blisters. Nurses must carefully assess the wound bed to ensure it is not a Stage
III or IV injury.
2. When a wound heals by primary intention, which of the following characteristics is
typically observed?
A. The wound is left open to heal by granulation.
B. The wound requires skin grafting to close the defect.
C. There is a high risk of infection and extensive tissue loss.
,D. The wound edges are well-approximated with minimal scarring.
Correct Answer: D
Expert Explanation: Primary intention healing occurs when wound edges are pulled
together and secured with sutures, staples, or adhesive. This process results in minimal
tissue loss and a very fine scar. It is the preferred method for clean surgical incisions
without significant contamination.
3. A nurse observes thick, yellow drainage on a patient’s surgical dressing. How should the
nurse document this type of exudate?
A. Serous
B. Sanguineous
C. Purulent
D. Serosanguineous
Correct Answer: C
Expert Explanation: Purulent drainage is thick and consists of white blood cells, dead
tissue, and bacteria, often appearing yellow, green, or brown. It is a significant indicator of
a localized infection in the wound site. Documentation must include the color, odor, and
consistency of this drainage for accurate clinical tracking.
4. Which nutrition component is most critical for a patient who is recovering from major
surgery and has multiple stage III pressure ulcers?
A. Vitamin K
, B. Carbohydrates
C. Fats
D. Protein
Correct Answer: D
Expert Explanation: Protein is essential for tissue repair, collagen synthesis, and immune
system function during the wound healing process. A deficiency in protein can lead to
delayed healing and increased risk of wound dehiscence. Nurses should collaborate with
dietitians to ensure patients receive adequate caloric and protein intake for recovery.
5. A patient is 5 days postoperative and reports a ‘popping’ sensation after coughing,
followed by a sudden increase in serosanguineous drainage. What should the nurse suspect?
A. Evisceration
B. Dehiscence
C. Internal hemorrhage
D. Normal healing progress
Correct Answer: B
Expert Explanation: Dehiscence is the partial or total separation of wound layers, often
occurring after sudden strain like coughing or sneezing. It is a serious complication that
requires immediate assessment of the wound and notification of the surgical team.
Serosanguineous fluid drainage is a classic early warning sign of this mechanical failure.
