NR 229 CH. 48 Skin Integrity and Wound Care Question and
answer verified to pass 2025 updated
1. A nurse participating in a a. Decreased level of consciousness
research project
associated with pressure Patients who are confused or disoriented or who have
ulcers will as- sess for changing levels of consciousness are unable to protect
what predisposing factor themselves. The patient may feel the pressure but may
that tends to increase not understand what to
the risk for pressure ulcer de- do to relieve the discomfort or to communicate that he
or she is
velopment? feeling discomfort.
a. Decreased level of Impaired sensory perception, impaired mobility, shear,
con- sciousness fric- tion, and moisture are other predisposing factors.
b. Adequate dietary intake
Shortness of breath, muscular pain, and an adequate
c. Shortness of breath
dietary intake are not included among the predisposing
d. Muscular pain factors.
2. The nurse caring for an
un- conscious patient who
was involved in an b. Pressure
automobile accident 2
Pressure is the main element that causes pressure ulcers.
weeks ago will give
Three pressure-related factors contribute to pressure
priority to which ele-
ulcer develop- ment: pressure intensity, pressure duration,
ment when planning care
and tissue tolerance. When the intensity of the pressure
to
exerted on the capillary ex-
decrease the development of ceeds 15 to 32 mm Hg, this occludes the vessel,
causing ischemic
a decubitus ulcer? observation will indicate the patient
a. Resistance is at
b. Pressure
c. Weight
d. Stress
3. Which nursing
,NR 229 CH. 48 Skin Integrity and Wound Care Question and
answer verified to pass 2025 updated
injury to the tissues it normally feeds. High weight are not the priority causes of pressure ulcers.
pressure over a short time and low
pressure over a long-time cause skin
breakdown. Resistance, stress, and a. Fecal incontinence
risk for pressure ulcer forma- The presence and duration of moisture on the skin
increase the
tion? risk of ulcer formation by making it susceptible to injury.
a. Fecal incontinence Moisture can originate from wound drainage, excessive
b. Ate two thirds of perspiration, and fecal or urinary incontinence. Bacteria
breakfast and enzymes in the stool
,NR 229 CH. 48 Skin Integrity and Wound Care Question and
answer verified to pass 2025 updated
c. A raised red rash on can enhance the opportunity for skin breakdown
the right shin
because the skin is moistened and softened, causing
maceration. Eating a
d. Capillary refill is less than 2 balanced diet is important for nutrition but eating just
two thirds
seconds of the meal does not indicate that the individual is at risk. A
raised red rash on the leg again is a concern and can attect
the integrity of the skin, but it is located on the shin, which
is not a high-risk area for skin breakdown. Pressure can
influence capillary refill, leading to skin breakdown, but
4. The wound care nurse this capillary response is within normal limits.
is monitoring a patient
with a Stage III c. Healing Stage III pressure ulcer
pressure ulcer
whose wound presents When a pressure ulcer has been staged and is beginning
with healthy tissue. How
should the nurse to heal, the ulcer keeps the same stage and is labeled
document this ul- cer in with the words
the patient's medical ―healing stage or healing Stage III pressure ulcer.
record?
Once an ulcer has been staged, the stage endures even
a. Stage I pressure ulcer
b. Healing Stage II as the ulcer heals. This ulcer was labeled a Stage III, and
pressure ulcer it cannot return to a previous stage such as Stage I or II.
c. Healing Stage III This ulcer is healing, so it
pressure ulcer
is no longer labeled a Stage III.
d. Stage III pressure ulcer
5. The nurse admitting an
old- er patient notes a
shallow
b. Stage II
open reddish, pink ulcer with- This would be a Stage II pressure ulcer because it
presents as
, NR 229 CH. 48 Skin Integrity and Wound Care Question and
answer verified to pass 2025 updated
out slough on the right partial-thickness skin loss involving epidermis and
heel of the patient. How
will the nurse stage this dermis. The ulcer presents clinically as an abrasion, blister,
pressure ul- cer? or shallow crater. Stage I is intact skin with non-
blanchable redness over a bony prominence. With a
Stage III pressure ulcer, subcutaneous fat
answer verified to pass 2025 updated
1. A nurse participating in a a. Decreased level of consciousness
research project
associated with pressure Patients who are confused or disoriented or who have
ulcers will as- sess for changing levels of consciousness are unable to protect
what predisposing factor themselves. The patient may feel the pressure but may
that tends to increase not understand what to
the risk for pressure ulcer de- do to relieve the discomfort or to communicate that he
or she is
velopment? feeling discomfort.
a. Decreased level of Impaired sensory perception, impaired mobility, shear,
con- sciousness fric- tion, and moisture are other predisposing factors.
b. Adequate dietary intake
Shortness of breath, muscular pain, and an adequate
c. Shortness of breath
dietary intake are not included among the predisposing
d. Muscular pain factors.
2. The nurse caring for an
un- conscious patient who
was involved in an b. Pressure
automobile accident 2
Pressure is the main element that causes pressure ulcers.
weeks ago will give
Three pressure-related factors contribute to pressure
priority to which ele-
ulcer develop- ment: pressure intensity, pressure duration,
ment when planning care
and tissue tolerance. When the intensity of the pressure
to
exerted on the capillary ex-
decrease the development of ceeds 15 to 32 mm Hg, this occludes the vessel,
causing ischemic
a decubitus ulcer? observation will indicate the patient
a. Resistance is at
b. Pressure
c. Weight
d. Stress
3. Which nursing
,NR 229 CH. 48 Skin Integrity and Wound Care Question and
answer verified to pass 2025 updated
injury to the tissues it normally feeds. High weight are not the priority causes of pressure ulcers.
pressure over a short time and low
pressure over a long-time cause skin
breakdown. Resistance, stress, and a. Fecal incontinence
risk for pressure ulcer forma- The presence and duration of moisture on the skin
increase the
tion? risk of ulcer formation by making it susceptible to injury.
a. Fecal incontinence Moisture can originate from wound drainage, excessive
b. Ate two thirds of perspiration, and fecal or urinary incontinence. Bacteria
breakfast and enzymes in the stool
,NR 229 CH. 48 Skin Integrity and Wound Care Question and
answer verified to pass 2025 updated
c. A raised red rash on can enhance the opportunity for skin breakdown
the right shin
because the skin is moistened and softened, causing
maceration. Eating a
d. Capillary refill is less than 2 balanced diet is important for nutrition but eating just
two thirds
seconds of the meal does not indicate that the individual is at risk. A
raised red rash on the leg again is a concern and can attect
the integrity of the skin, but it is located on the shin, which
is not a high-risk area for skin breakdown. Pressure can
influence capillary refill, leading to skin breakdown, but
4. The wound care nurse this capillary response is within normal limits.
is monitoring a patient
with a Stage III c. Healing Stage III pressure ulcer
pressure ulcer
whose wound presents When a pressure ulcer has been staged and is beginning
with healthy tissue. How
should the nurse to heal, the ulcer keeps the same stage and is labeled
document this ul- cer in with the words
the patient's medical ―healing stage or healing Stage III pressure ulcer.
record?
Once an ulcer has been staged, the stage endures even
a. Stage I pressure ulcer
b. Healing Stage II as the ulcer heals. This ulcer was labeled a Stage III, and
pressure ulcer it cannot return to a previous stage such as Stage I or II.
c. Healing Stage III This ulcer is healing, so it
pressure ulcer
is no longer labeled a Stage III.
d. Stage III pressure ulcer
5. The nurse admitting an
old- er patient notes a
shallow
b. Stage II
open reddish, pink ulcer with- This would be a Stage II pressure ulcer because it
presents as
, NR 229 CH. 48 Skin Integrity and Wound Care Question and
answer verified to pass 2025 updated
out slough on the right partial-thickness skin loss involving epidermis and
heel of the patient. How
will the nurse stage this dermis. The ulcer presents clinically as an abrasion, blister,
pressure ul- cer? or shallow crater. Stage I is intact skin with non-
blanchable redness over a bony prominence. With a
Stage III pressure ulcer, subcutaneous fat
