2O & NIKS • 2 MAXE
Nursing Fundamentals
NURS School of Nursing — Exam 2 Review
T I S S U E I N T E G R I T Y · O X Y G E N AT I O N · P E R F U S I O N · N U T R I T I O N
EXAM 2
Exam 2 — Nursing Fundamentals
T I SS U E I N T E G R I TY, E L I M I N AT I O N , N U T R I T I O N , OX YG E N AT I O N & P E R F U S I O N
INSTITUTION School of Nursing COURSE CODE NURS-FUND-EXAM2
PROGRAM Nursing — ADN / BSN Pathway ACADEMIC YEAR
EXAM TITLE Exam 2 — Tissue Integrity, Oxygenation, TOTAL QUESTIONS 50+ Comprehensive Questions
Perfusion
COURSE TITLE Nursing Fundamentals FORMAT Multiple Choice / Definition / Select All
That Apply
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise indicated.
▸ Questions cover skin integrity (Braden Scale), oxygenation (respiratory assessment, breathing patterns), perfusion (cardiac
output, heart sounds, pulse assessment), and related nursing interventions.
▸ Verified answers with detailed rationales are provided for comprehensive exam preparation.
▸ Pay close attention to the six Braden Scale subscales, heart sound auscultation landmarks, and the differences between
preload, afterload, and ejection fraction.
SKIN INTEGRITY, OXYGENATION & PERFUSION ASSESSMENT Questions 1 – 50+
1. What are the six key components to assess when evaluating skin integrity?
A. Only color and temperature.
B. Skin color, moisture, skin lesions, integrity, texture, and temperature.
C. Only lesions and moisture.
D. Skin assessment is not a nursing responsibility.
CORRECT ANSWER B — Color, moisture, lesions, integrity, texture, and temperature
RATIONALE Comprehensive skin assessment examines six components: Color — assess for pallor, cyanosis, jaundice,
erythema, ecchymosis. Moisture — excessive dryness or moisture increases breakdown risk. Skin lesions —
document type, size, location, distribution (use ABCDE for moles). Integrity — assess for any breaks, wounds,
rashes, pressure injuries. Texture — smooth, rough, scaly. Temperature — warm, cool, hot to touch; compare
bilaterally. Skin assessment should be performed on admission, at least daily, and with any change in
condition. It is the first line of defense in preventing pressure injuries and identifying systemic disease
manifestations.
, 2. What are the age-related impacts on tissue integrity?
A. Skin becomes thicker and more elastic with aging.
B. Loss of skin turgor, thinner skin, decreased peripheral circulation, and redistribution of subcutaneous fat.
C. Aging does not affect skin integrity.
D. Only the epidermis thins; other layers are unaffected.
CORRECT ANSWER B — Loss of turgor, thinner skin, decreased peripheral circulation, subcutaneous fat redistribution
RATIONALE Aging causes multiple skin changes that increase vulnerability: Decreased skin turgor (elasticity) — skin tents
when pinched and is slow to return; caused by dermal collagen and elastin loss. Thinner epidermis and
dermis — more susceptible to tears, shearing, and pressure injury. Decreased peripheral circulation —
impaired delivery of oxygen and nutrients slows wound healing and increases infection risk. Redistribution of
subcutaneous fat — loss of protective padding over bony prominences (sacrum, heels, elbows) increases
pressure injury risk. Decreased sebaceous gland activity — drier skin, more prone to cracking. Decreased
melanocytes — uneven pigmentation but also reduced UV protection. These changes require meticulous skin
care, frequent repositioning, and nutritional support.
3. What are the six subscales of the Braden Scale for Predicting Pressure Sore Risk?
A. Pain, temperature, pulse, respiration, oxygen, consciousness.
B. Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear.
C. Color, edema, pain, temperature, turgor, lesions.
D. Only mobility and nutrition.
CORRECT ANSWER B — Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear
RATIONALE The Braden Scale evaluates six risk subscales scored 1-4 (friction/shear scored 1-3): Sensory Perception —
ability to respond meaningfully to pressure-related discomfort (1 = completely limited, 4 = no impairment).
Moisture — degree to which skin is exposed to moisture (1 = constantly moist, 4 = rarely moist). Activity —
degree of physical activity (1 = bedfast, 4 = walks frequently). Mobility — ability to change and control body
position (1 = completely immobile, 4 = no limitations). Nutrition — usual food intake pattern (1 = very poor, 4 =
excellent). Friction and Shear — (1 = problem, 3 = no apparent problem). Total scores: 15-18 = mild risk, 13-14
= moderate risk, 10-12 = high risk, ≤9 = very high risk. Nursing interventions are tailored to each subscale
deficit. For example, low sensory perception requires scheduled repositioning and skin assessment; high
moisture requires barrier creams and absorbent products.
4. How do medications affect tissue integrity and wound healing?
A. All medications promote wound healing.
B. Medications like steroids reduce collagen production and have a depressant effect on wound healing. Other
medications may affect circulation, nutrition, or immune function.
C. Medications have no effect on tissue integrity.
D. Only topical medications affect skin.
CORRECT ANSWER B — Steroids reduce collagen production and depress wound healing; other meds affect
circulation/nutrition/immunity
RATIONALE Multiple medication classes impair tissue integrity and wound healing: Corticosteroids — suppress
inflammation, reduce collagen synthesis, decrease fibroblast proliferation, and impair epithelialization;
patients on chronic steroids have significantly delayed wound healing and increased infection risk. NSAIDs —
may impair healing by inhibiting prostaglandin synthesis needed for inflammation (the first phase of healing).
Anticoagulants/antiplatelets — increase bleeding/bruising risk. Chemotherapy agents — suppress bone
marrow, decrease WBCs (infection risk), impair cell division needed for tissue repair. Vasopressors —
peripheral vasoconstriction reduces blood flow to skin, increasing ischemia risk. Immunosuppressants —
decrease resistance to infection. Nurses must assess medication history as part of skin/wound assessment
and monitor for complications.
Nursing Fundamentals
NURS School of Nursing — Exam 2 Review
T I S S U E I N T E G R I T Y · O X Y G E N AT I O N · P E R F U S I O N · N U T R I T I O N
EXAM 2
Exam 2 — Nursing Fundamentals
T I SS U E I N T E G R I TY, E L I M I N AT I O N , N U T R I T I O N , OX YG E N AT I O N & P E R F U S I O N
INSTITUTION School of Nursing COURSE CODE NURS-FUND-EXAM2
PROGRAM Nursing — ADN / BSN Pathway ACADEMIC YEAR
EXAM TITLE Exam 2 — Tissue Integrity, Oxygenation, TOTAL QUESTIONS 50+ Comprehensive Questions
Perfusion
COURSE TITLE Nursing Fundamentals FORMAT Multiple Choice / Definition / Select All
That Apply
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise indicated.
▸ Questions cover skin integrity (Braden Scale), oxygenation (respiratory assessment, breathing patterns), perfusion (cardiac
output, heart sounds, pulse assessment), and related nursing interventions.
▸ Verified answers with detailed rationales are provided for comprehensive exam preparation.
▸ Pay close attention to the six Braden Scale subscales, heart sound auscultation landmarks, and the differences between
preload, afterload, and ejection fraction.
SKIN INTEGRITY, OXYGENATION & PERFUSION ASSESSMENT Questions 1 – 50+
1. What are the six key components to assess when evaluating skin integrity?
A. Only color and temperature.
B. Skin color, moisture, skin lesions, integrity, texture, and temperature.
C. Only lesions and moisture.
D. Skin assessment is not a nursing responsibility.
CORRECT ANSWER B — Color, moisture, lesions, integrity, texture, and temperature
RATIONALE Comprehensive skin assessment examines six components: Color — assess for pallor, cyanosis, jaundice,
erythema, ecchymosis. Moisture — excessive dryness or moisture increases breakdown risk. Skin lesions —
document type, size, location, distribution (use ABCDE for moles). Integrity — assess for any breaks, wounds,
rashes, pressure injuries. Texture — smooth, rough, scaly. Temperature — warm, cool, hot to touch; compare
bilaterally. Skin assessment should be performed on admission, at least daily, and with any change in
condition. It is the first line of defense in preventing pressure injuries and identifying systemic disease
manifestations.
, 2. What are the age-related impacts on tissue integrity?
A. Skin becomes thicker and more elastic with aging.
B. Loss of skin turgor, thinner skin, decreased peripheral circulation, and redistribution of subcutaneous fat.
C. Aging does not affect skin integrity.
D. Only the epidermis thins; other layers are unaffected.
CORRECT ANSWER B — Loss of turgor, thinner skin, decreased peripheral circulation, subcutaneous fat redistribution
RATIONALE Aging causes multiple skin changes that increase vulnerability: Decreased skin turgor (elasticity) — skin tents
when pinched and is slow to return; caused by dermal collagen and elastin loss. Thinner epidermis and
dermis — more susceptible to tears, shearing, and pressure injury. Decreased peripheral circulation —
impaired delivery of oxygen and nutrients slows wound healing and increases infection risk. Redistribution of
subcutaneous fat — loss of protective padding over bony prominences (sacrum, heels, elbows) increases
pressure injury risk. Decreased sebaceous gland activity — drier skin, more prone to cracking. Decreased
melanocytes — uneven pigmentation but also reduced UV protection. These changes require meticulous skin
care, frequent repositioning, and nutritional support.
3. What are the six subscales of the Braden Scale for Predicting Pressure Sore Risk?
A. Pain, temperature, pulse, respiration, oxygen, consciousness.
B. Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear.
C. Color, edema, pain, temperature, turgor, lesions.
D. Only mobility and nutrition.
CORRECT ANSWER B — Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear
RATIONALE The Braden Scale evaluates six risk subscales scored 1-4 (friction/shear scored 1-3): Sensory Perception —
ability to respond meaningfully to pressure-related discomfort (1 = completely limited, 4 = no impairment).
Moisture — degree to which skin is exposed to moisture (1 = constantly moist, 4 = rarely moist). Activity —
degree of physical activity (1 = bedfast, 4 = walks frequently). Mobility — ability to change and control body
position (1 = completely immobile, 4 = no limitations). Nutrition — usual food intake pattern (1 = very poor, 4 =
excellent). Friction and Shear — (1 = problem, 3 = no apparent problem). Total scores: 15-18 = mild risk, 13-14
= moderate risk, 10-12 = high risk, ≤9 = very high risk. Nursing interventions are tailored to each subscale
deficit. For example, low sensory perception requires scheduled repositioning and skin assessment; high
moisture requires barrier creams and absorbent products.
4. How do medications affect tissue integrity and wound healing?
A. All medications promote wound healing.
B. Medications like steroids reduce collagen production and have a depressant effect on wound healing. Other
medications may affect circulation, nutrition, or immune function.
C. Medications have no effect on tissue integrity.
D. Only topical medications affect skin.
CORRECT ANSWER B — Steroids reduce collagen production and depress wound healing; other meds affect
circulation/nutrition/immunity
RATIONALE Multiple medication classes impair tissue integrity and wound healing: Corticosteroids — suppress
inflammation, reduce collagen synthesis, decrease fibroblast proliferation, and impair epithelialization;
patients on chronic steroids have significantly delayed wound healing and increased infection risk. NSAIDs —
may impair healing by inhibiting prostaglandin synthesis needed for inflammation (the first phase of healing).
Anticoagulants/antiplatelets — increase bleeding/bruising risk. Chemotherapy agents — suppress bone
marrow, decrease WBCs (infection risk), impair cell division needed for tissue repair. Vasopressors —
peripheral vasoconstriction reduces blood flow to skin, increasing ischemia risk. Immunosuppressants —
decrease resistance to infection. Nurses must assess medication history as part of skin/wound assessment
and monitor for complications.
