NSG 121/ NSG121 (Latest 2024/ 2025 Update) Health
Assessment Review | Questions and Verified Answers| All
Units Covered| 100% Correct| Grade A- Herzing
Ischemic lesions of the skin and tissues caused by unrelieved pressure that
interferes with blood and lymph flow - ANSWER pressure ulcers
dead tissue - ANSWER necrosis
A nurse identifies that a client has a pressure ulcer on the sacrum. Which
assessment finding indicates that this is a stage III pressure ulcer?
A. Non-blanchable erythema of intact skin
B. Damage identifies to muscle and bone
C. Skin loss to the dermis
D. Necrosis of subcutaneous tissue - ANSWER D
An 88-year-old client who has limited mobility is admitted to the hospital. Which
action by the nurse prevents injury to the skin normally caused by friction?
A. Avoiding use of a draw sheet when repositioning the client
B. Sprinkling baby powder on the sheets to keep the skin dry
C. Placing the client in the prone position
D. Elevating the head of the bed to a 60-degree angle - ANSWER C
A client with type 1 diabetes mellitus has a blister on the left heel that resulted from
improperly fitting shoes. The nurse should document this ulcer as being which
stage?
A. Stage II
B. Stage III
C. Stage IV
D. Stage I - ANSWER A
The nurse identifies that a client admitted for decreased mental status is at risk for a
pressure ulcer. Which action assists in maintaining skin hygiene to help prevent a
pressure ulcer?
A. Applying lotion to moist skin after the bath
B. Massaging bony prominences during the bath
C. Using hot water and mild soap during the bath
D. Monitoring the skin once a week during the bath - ANSWER A
When planning care for a client at risk for developing a pressure ulcer, the nurse
addresses the potential problem of risk for impaired skin integrity. Which nursing
intervention assists in meeting the goals of this diagnosis? (Select all that apply.)
,A. Avoiding massaging bony prominences
B. Placing the client in the side-lying position only
C. Keeping the head of the bed elevated more than thirty degrees
D. Inspecting the skin every day
E. Using positioning devices - ANSWER A, D, and E
The nurse is caring for a client with a stage I pressure ulcer to the sacrum. Which
product should the nurse use to help increase blood supply to the skin of this
pressure ulcer?
A. Transparent dressing
B. Vacuum-assisted closure
C. Hydrogel dressing
D. Granulex - ANSWER D
Which action maintains skin hygiene for clients at risk for pressure ulcers? (Select all
that apply.)
A. Avoiding exposure to high humidity
B. Scrubbing the skin to clean it thoroughly when bathing
C. Treating dry skin with moisturizing lotions directly applied to moist skin after
bathing
D. Cleaning the skin immediately if exposed to urine or feces
E. Assessing the skin upon admission and then daily using the same screening tool -
ANSWER C, D, and E
Which factor contributes to the formation of pressure ulcers in a client and increases
the cells' need for oxygen?
A. Immobility
B. Diminished sensation
C. Inadequate nutrition
D. Excessive body heat - ANSWER D
Which type of debridement causes the least damage to healthy and healing tissue
surrounding a pressure ulcer?
A. Autolytic
B. Chemical
C. Mechanical
D. Sharp - ANSWER A
Which type of product or dressing for pressure ulcers forms a gel when it comes in
contact with wound exudate?
A. Alginate dressing
B. Hydrofiber dressing
C. Proteolytic enzymes
D. Hydrocolloid dressing - ANSWER A
,Which data should you record when assessing an existing pressure ulcer? (Select all
that apply.)
A. Odor of wound bed
B. Color of the wound bed
C. Location in relation to bony prominences
D. Condition of the wound margins
E. Signs of infection - ANSWER B, C, D, and E
The nurse is caring for a client with a pressure ulcer who is at risk for impaired skin
integrity. Which intervention should be included in the nursing plan of care? (Select
all that apply.)
A. Cleaning the skin at time of soiling and routinely
B. Inspecting skin at least once a day
C. Increasing amount of time with the head of the bed elevated
D. Avoiding the side-lying position
E. Massaging bony prominences - ANSWER A, B, and D
Mr. Brown is being treated for pressure ulcers. Mr. Brown has dementia and limited
mobility, and he lives with his daughter, spending most of his day sitting in a chair.
What should you suggest to Mr. Brown's daughter to help reduce his risk for
pressure ulcers?
A. "Reposition Mr. Brown in the chair every 3 hours."
B. "Place a memory foam pad on Mr. Brown's chair."
C. "Have Mr. Brown sit in a more comfortable chair."
D. "Have Mr. Brown stay in bed rather than sit in a chair." - ANSWER B
Mr. Flores has a chronic pressure ulcer, and test results show significant bacterial
growth in the wound. The healthcare provider has prescribed larval therapy, and Mr.
Flores asks you to explain how putting maggots on his pressure ulcer will help.
Which is your best response?
A. "The maggots will eat the bacteria and reduce bacterial growth on your pressure
ulcer."
B. "The maggots secrete an enzyme that will make your pressure ulcer less painful."
C. "The maggots will help your pressure ulcer to drain."
D. "The maggots are the fastest method for treating a pressure ulcer." - ANSWER
A
Mrs. Como is bedridden and lives with her son and his family. You are helping to
treat her for pressure ulcers that appear to be caused by frequent incontinence.
While speaking with Mrs. Como, you learn that she feels ignored by her son and his
, family and is depressed about her situation. What should you include in the nursing
care for Mrs. Como to address her situational low self-esteem?
A. Encouraging Mrs. Como's family to speak to her more often
B. Encouraging Mrs. Como's family to bring her to the healthcare provider more often
C. Teaching Mrs. Como to rely on herself for her own skin hygiene
D. Teaching Mrs. Como's family how to conduct skin hygiene for her - ANSWER D
A client who is confined to bed is at risk for developing a pressure ulcer. What
support surface should the nurse request for this client?
A. Kinetic bed
B. Memory foam mattress
C. Gel flotation pads
D. Alternating pressure mattress - ANSWER A
While assessing the skin of a surgical client, the nurse observes erythema to the left
scapulae. What is the best action for the nurse to take before reassessing the skin to
determine if the erythema is a pressure ulcer?
A. Covering the area with a dressing
B. Repositioning the client
C. Applying a warm blanket
D. Massaging the scapulae with lotion - ANSWER B
The charge nurse has just received the report for all clients on the unit. Which client
should the nurse consider as being at risk for the development of pressure ulcers?
(Select all that apply.)
A. The client who has type 1 diabetes mellitus
B. The client who is 92 years old
C. The client who is on bed rest
D. The client who is admitted to an acute care unit
E. The client who has a history of anorexia nervosa - ANSWER A, B, C, and E
The nurse is educating a student about alginate dressings. On what type of pressure
ulcer is this type of dressing used? (Select all that apply.)
A. Stage II
B. Stage III
C. Stage I
D. Stage IV with eschar
E. Stage IV without eschar - ANSWER A, B, and E
The nurse is caring for a client admitted with a pressure ulcer. Which data should the
nurse document when assessing the pressure ulcer? (Select all that apply.)
Assessment Review | Questions and Verified Answers| All
Units Covered| 100% Correct| Grade A- Herzing
Ischemic lesions of the skin and tissues caused by unrelieved pressure that
interferes with blood and lymph flow - ANSWER pressure ulcers
dead tissue - ANSWER necrosis
A nurse identifies that a client has a pressure ulcer on the sacrum. Which
assessment finding indicates that this is a stage III pressure ulcer?
A. Non-blanchable erythema of intact skin
B. Damage identifies to muscle and bone
C. Skin loss to the dermis
D. Necrosis of subcutaneous tissue - ANSWER D
An 88-year-old client who has limited mobility is admitted to the hospital. Which
action by the nurse prevents injury to the skin normally caused by friction?
A. Avoiding use of a draw sheet when repositioning the client
B. Sprinkling baby powder on the sheets to keep the skin dry
C. Placing the client in the prone position
D. Elevating the head of the bed to a 60-degree angle - ANSWER C
A client with type 1 diabetes mellitus has a blister on the left heel that resulted from
improperly fitting shoes. The nurse should document this ulcer as being which
stage?
A. Stage II
B. Stage III
C. Stage IV
D. Stage I - ANSWER A
The nurse identifies that a client admitted for decreased mental status is at risk for a
pressure ulcer. Which action assists in maintaining skin hygiene to help prevent a
pressure ulcer?
A. Applying lotion to moist skin after the bath
B. Massaging bony prominences during the bath
C. Using hot water and mild soap during the bath
D. Monitoring the skin once a week during the bath - ANSWER A
When planning care for a client at risk for developing a pressure ulcer, the nurse
addresses the potential problem of risk for impaired skin integrity. Which nursing
intervention assists in meeting the goals of this diagnosis? (Select all that apply.)
,A. Avoiding massaging bony prominences
B. Placing the client in the side-lying position only
C. Keeping the head of the bed elevated more than thirty degrees
D. Inspecting the skin every day
E. Using positioning devices - ANSWER A, D, and E
The nurse is caring for a client with a stage I pressure ulcer to the sacrum. Which
product should the nurse use to help increase blood supply to the skin of this
pressure ulcer?
A. Transparent dressing
B. Vacuum-assisted closure
C. Hydrogel dressing
D. Granulex - ANSWER D
Which action maintains skin hygiene for clients at risk for pressure ulcers? (Select all
that apply.)
A. Avoiding exposure to high humidity
B. Scrubbing the skin to clean it thoroughly when bathing
C. Treating dry skin with moisturizing lotions directly applied to moist skin after
bathing
D. Cleaning the skin immediately if exposed to urine or feces
E. Assessing the skin upon admission and then daily using the same screening tool -
ANSWER C, D, and E
Which factor contributes to the formation of pressure ulcers in a client and increases
the cells' need for oxygen?
A. Immobility
B. Diminished sensation
C. Inadequate nutrition
D. Excessive body heat - ANSWER D
Which type of debridement causes the least damage to healthy and healing tissue
surrounding a pressure ulcer?
A. Autolytic
B. Chemical
C. Mechanical
D. Sharp - ANSWER A
Which type of product or dressing for pressure ulcers forms a gel when it comes in
contact with wound exudate?
A. Alginate dressing
B. Hydrofiber dressing
C. Proteolytic enzymes
D. Hydrocolloid dressing - ANSWER A
,Which data should you record when assessing an existing pressure ulcer? (Select all
that apply.)
A. Odor of wound bed
B. Color of the wound bed
C. Location in relation to bony prominences
D. Condition of the wound margins
E. Signs of infection - ANSWER B, C, D, and E
The nurse is caring for a client with a pressure ulcer who is at risk for impaired skin
integrity. Which intervention should be included in the nursing plan of care? (Select
all that apply.)
A. Cleaning the skin at time of soiling and routinely
B. Inspecting skin at least once a day
C. Increasing amount of time with the head of the bed elevated
D. Avoiding the side-lying position
E. Massaging bony prominences - ANSWER A, B, and D
Mr. Brown is being treated for pressure ulcers. Mr. Brown has dementia and limited
mobility, and he lives with his daughter, spending most of his day sitting in a chair.
What should you suggest to Mr. Brown's daughter to help reduce his risk for
pressure ulcers?
A. "Reposition Mr. Brown in the chair every 3 hours."
B. "Place a memory foam pad on Mr. Brown's chair."
C. "Have Mr. Brown sit in a more comfortable chair."
D. "Have Mr. Brown stay in bed rather than sit in a chair." - ANSWER B
Mr. Flores has a chronic pressure ulcer, and test results show significant bacterial
growth in the wound. The healthcare provider has prescribed larval therapy, and Mr.
Flores asks you to explain how putting maggots on his pressure ulcer will help.
Which is your best response?
A. "The maggots will eat the bacteria and reduce bacterial growth on your pressure
ulcer."
B. "The maggots secrete an enzyme that will make your pressure ulcer less painful."
C. "The maggots will help your pressure ulcer to drain."
D. "The maggots are the fastest method for treating a pressure ulcer." - ANSWER
A
Mrs. Como is bedridden and lives with her son and his family. You are helping to
treat her for pressure ulcers that appear to be caused by frequent incontinence.
While speaking with Mrs. Como, you learn that she feels ignored by her son and his
, family and is depressed about her situation. What should you include in the nursing
care for Mrs. Como to address her situational low self-esteem?
A. Encouraging Mrs. Como's family to speak to her more often
B. Encouraging Mrs. Como's family to bring her to the healthcare provider more often
C. Teaching Mrs. Como to rely on herself for her own skin hygiene
D. Teaching Mrs. Como's family how to conduct skin hygiene for her - ANSWER D
A client who is confined to bed is at risk for developing a pressure ulcer. What
support surface should the nurse request for this client?
A. Kinetic bed
B. Memory foam mattress
C. Gel flotation pads
D. Alternating pressure mattress - ANSWER A
While assessing the skin of a surgical client, the nurse observes erythema to the left
scapulae. What is the best action for the nurse to take before reassessing the skin to
determine if the erythema is a pressure ulcer?
A. Covering the area with a dressing
B. Repositioning the client
C. Applying a warm blanket
D. Massaging the scapulae with lotion - ANSWER B
The charge nurse has just received the report for all clients on the unit. Which client
should the nurse consider as being at risk for the development of pressure ulcers?
(Select all that apply.)
A. The client who has type 1 diabetes mellitus
B. The client who is 92 years old
C. The client who is on bed rest
D. The client who is admitted to an acute care unit
E. The client who has a history of anorexia nervosa - ANSWER A, B, C, and E
The nurse is educating a student about alginate dressings. On what type of pressure
ulcer is this type of dressing used? (Select all that apply.)
A. Stage II
B. Stage III
C. Stage I
D. Stage IV with eschar
E. Stage IV without eschar - ANSWER A, B, and E
The nurse is caring for a client admitted with a pressure ulcer. Which data should the
nurse document when assessing the pressure ulcer? (Select all that apply.)
