CHAPTER 48 (SKIN INTEGRITY &
WOUND CARE). EXAM 2025/2026
QUESTIONS AND ANSWERS
A nurse participating in a research project associated with pressure ulcers will assess for what
predisposing factor that tends to increase the risk for pressure ulcer development?
A. Decreased level of consciousness
B. Adequate dietary intake
C. Shortness of breath
D. Muscular pain - ANS A. Decreased level of consciousness
The nurse caring for an unconscious patient who was involved in an automobile accident 2
weeks ago will give priority to which element when planning care to decrease the development
of a decubitus ulcer?
A. Resistance
B. Pressure
C. Weight
D. Stress - ANS B. Pressure
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
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,A. Fecal incontinence
B. Ate two thirds of breakfast
C. A raised red rash on the right shin
D. Capillary refill is less than 2 seconds - ANS A. Fecal incontinence
The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound
presents with healthy tissue. How should the nurse document this ulcer in the patient's medical
record?
A. Stage I pressure ulcer
B. Healing Stage II pressure ulcer
C. Healing Stage III pressure ulcer
D. Stage III pressure ulcer - ANS C. Healing Stage III pressure ulcer
The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough
on the right heel of the patient. How will the nurse stage this pressure ulcer?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV - ANS B. Stage II
Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly
pigmented skin patient?
A. Disposable measuring tape
B. Cotton-tipped applicator
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, C. Sterile gloves
D. Natural light - ANS D. Natural light
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the
nurse consider when planning care for this patient?
A. Partial-thickness wound repair
B. Full-thickness wound repair
C. Primary intention
D. Tertiary intention - ANS B. Full-thickness wound repair
The nurse is caring for a group of patients. Which patient will the nurse see first?
A. A patient with a Stage IV pressure ulcer
B. A patient with a Braden Scale score of 18
C. A patient with appendicitis using a heating pad
D. A patient with an incision that is approximated - ANS C. A patient with appendicitis using a
heating pad
The nurse is caring for a patient who is experiencing a full-thickness wound repair. Which type
of tissue will the nurse expect to observe when the wound is healing?
A. Eschar
B. Slough
C. Granulation
D. Purulent drainage - ANS C. Granulation
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WOUND CARE). EXAM 2025/2026
QUESTIONS AND ANSWERS
A nurse participating in a research project associated with pressure ulcers will assess for what
predisposing factor that tends to increase the risk for pressure ulcer development?
A. Decreased level of consciousness
B. Adequate dietary intake
C. Shortness of breath
D. Muscular pain - ANS A. Decreased level of consciousness
The nurse caring for an unconscious patient who was involved in an automobile accident 2
weeks ago will give priority to which element when planning care to decrease the development
of a decubitus ulcer?
A. Resistance
B. Pressure
C. Weight
D. Stress - ANS B. Pressure
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
1 | Page @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED
,A. Fecal incontinence
B. Ate two thirds of breakfast
C. A raised red rash on the right shin
D. Capillary refill is less than 2 seconds - ANS A. Fecal incontinence
The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound
presents with healthy tissue. How should the nurse document this ulcer in the patient's medical
record?
A. Stage I pressure ulcer
B. Healing Stage II pressure ulcer
C. Healing Stage III pressure ulcer
D. Stage III pressure ulcer - ANS C. Healing Stage III pressure ulcer
The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough
on the right heel of the patient. How will the nurse stage this pressure ulcer?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV - ANS B. Stage II
Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly
pigmented skin patient?
A. Disposable measuring tape
B. Cotton-tipped applicator
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, C. Sterile gloves
D. Natural light - ANS D. Natural light
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the
nurse consider when planning care for this patient?
A. Partial-thickness wound repair
B. Full-thickness wound repair
C. Primary intention
D. Tertiary intention - ANS B. Full-thickness wound repair
The nurse is caring for a group of patients. Which patient will the nurse see first?
A. A patient with a Stage IV pressure ulcer
B. A patient with a Braden Scale score of 18
C. A patient with appendicitis using a heating pad
D. A patient with an incision that is approximated - ANS C. A patient with appendicitis using a
heating pad
The nurse is caring for a patient who is experiencing a full-thickness wound repair. Which type
of tissue will the nurse expect to observe when the wound is healing?
A. Eschar
B. Slough
C. Granulation
D. Purulent drainage - ANS C. Granulation
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