WND 580 - MODULE 2 EXAM 2025
QUESTIONS AND ANSWERS
Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3 pressure injury
on her coccyx with undermining. Which of the following risk factors is most responsible for
undermining in the pressure injury?
a. Shear from having the head of bed elevated to 45 degrees.
b. Friction from her turning from side to side.
c. Local infection in the wound.
d. Excess moisture in the wound bed. - ANS a. Shear from having the head of bed elevated to
45 degrees.
A patient with paraplegia is in the wound clinic to have a new seating surface re-evaluated. You
notice a serous fluid filled blister on the left heel which you document as a pressure injury in
what Stage?
a. Stage 1.
b. Stage 2.
c. Stage 3.
d. Stage 4. - ANS b. Stage 2.
The care plan for the patient with a pressure risk assessment score (Braden Scale) of 9 and on a
therapeutic support surface should always include:
1|P a g e C o p y r i g h t © 2 0 2 5 T H E B R I G H T A L L R I G H T S R E S E R V E D
, a. Maintaining HOB at 45 degrees or less.
b. Reposition the patient every 2-4 hours depending upon tissue tolerance.
c. Use an artificial sheepskin under the coccyx to prevent shear.
d. Avoid the use of absorbent under pads in patients with incontinence. - ANS b. Reposition
the patient every 2-4 hours depending upon tissue tolerance.
Mr. Lee was found lying at home on the floor. Upon admission, he has an intact, nonblanchable,
persistent purple discoloration over the coccyx. Which describes the classification of his
pressure injury?
a. Deep tissue pressure injury.
b. Stage 1 pressure injury.
c. Unstageable.
d. Stage 3 pressure injury. - ANS a. Deep tissue pressure injury.
Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath. Which of the
following is considered a potential PRIMARY etiologic factor in the development of a pressure
injury for this patient?
a. Shear force
b. Short-term pressure force
c. Friction force
d. Presence of a medical device - ANS a. Shear force
Which area of the body is the MOST difficult to offload using a pressure redistribution surface?
a. Sacrum.
b. Occiput.
2|P a g e C o p y r i g h t © 2 0 2 5 T H E B R I G H T A L L R I G H T S R E S E R V E D
QUESTIONS AND ANSWERS
Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3 pressure injury
on her coccyx with undermining. Which of the following risk factors is most responsible for
undermining in the pressure injury?
a. Shear from having the head of bed elevated to 45 degrees.
b. Friction from her turning from side to side.
c. Local infection in the wound.
d. Excess moisture in the wound bed. - ANS a. Shear from having the head of bed elevated to
45 degrees.
A patient with paraplegia is in the wound clinic to have a new seating surface re-evaluated. You
notice a serous fluid filled blister on the left heel which you document as a pressure injury in
what Stage?
a. Stage 1.
b. Stage 2.
c. Stage 3.
d. Stage 4. - ANS b. Stage 2.
The care plan for the patient with a pressure risk assessment score (Braden Scale) of 9 and on a
therapeutic support surface should always include:
1|P a g e C o p y r i g h t © 2 0 2 5 T H E B R I G H T A L L R I G H T S R E S E R V E D
, a. Maintaining HOB at 45 degrees or less.
b. Reposition the patient every 2-4 hours depending upon tissue tolerance.
c. Use an artificial sheepskin under the coccyx to prevent shear.
d. Avoid the use of absorbent under pads in patients with incontinence. - ANS b. Reposition
the patient every 2-4 hours depending upon tissue tolerance.
Mr. Lee was found lying at home on the floor. Upon admission, he has an intact, nonblanchable,
persistent purple discoloration over the coccyx. Which describes the classification of his
pressure injury?
a. Deep tissue pressure injury.
b. Stage 1 pressure injury.
c. Unstageable.
d. Stage 3 pressure injury. - ANS a. Deep tissue pressure injury.
Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath. Which of the
following is considered a potential PRIMARY etiologic factor in the development of a pressure
injury for this patient?
a. Shear force
b. Short-term pressure force
c. Friction force
d. Presence of a medical device - ANS a. Shear force
Which area of the body is the MOST difficult to offload using a pressure redistribution surface?
a. Sacrum.
b. Occiput.
2|P a g e C o p y r i g h t © 2 0 2 5 T H E B R I G H T A L L R I G H T S R E S E R V E D
