NURSING FUNDAMENTALS TEST BANK 2025 | SKIN INTEGRITY,
WOUND CARE, AND PRESSURE ULCER MANAGEMENT |
HIGH-YIELD QUESTIONS WITH DETAILED ANSWERS &
GUARANTEED A+ SUCCESS.
1. The nurse is caring for a patient with a large abrasion from a motorcycle
accident. The nurse recalls that if the wound is kept moist, it can resurface in
_____ day(s).
a. 4
b. 2
c. 1
d. 7
☑️ CORRECT ANSWER: A
A partial-thickness wound repair has three compartments: the inflammatory response,
epithelial proliferation and migration, and re-establishment of the epidermal layers.
Epithelial proliferation and migration start at all edges of the wound, allowing for quick
resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound
occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is
kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur,
moist or dry.
2. The nurse is caring for a patient who is experiencing a full-thickness repair.
The nurse would expect to see which of the following in this type of repair?
a. Eschar
b. Slough
c. Granulation
d. Purulent drainage
☑️ CORRECT ANSWER: C
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of
which indicates progression toward healing. Soft yellow or white tissue is characteristic
of slough—a substance that needs to be removed for the wound to heal. Black or brown
necrotic tissue is called eschar, which also needs to be removed for a wound to heal.
Purulent drainage is indicative of an infection and will need to be resolved for the wound
to heal.
3. The nurse is caring for a patient who has experienced a laparoscopic
appendectomy. The nurse recalls that this type of wound heals by
a. Tertiary intention
,b. Secondary intention
c. Partial-thickness repair
d. Primary intention
☑️ CORRECT ANSWER: D
A clean surgical incision is an example of a wound with little loss of tissue that heals
with primary intention. The skin edges are approximated or closed, and the risk for
infection is low. Partial-thickness repairs are done on partial-thickness wounds that are
shallow, involving loss of the epidermis and maybe partial loss of the dermis. These
wounds heal by regeneration because the epidermis regenerates. Tertiary intention is
seen when a wound is left open for several days, and then the wound edges are
approximated. Wound closure is delayed until the risk of infection is resolved. A wound
involving loss of tissue such as a burn or a pressure ulcer or laceration heals by
secondary intention. The wound is left open until it becomes filled with scar tissue. It
takes longer for a wound to heal by secondary intention; thus the chance of infection is
greater.
4. The nurse is caring for a patient in the burn unit. The nurse recalls that this
type of wound heals by
a. Tertiary intention
b. Secondary intention
c. Partial-thickness repair
d. Primary intention
☑️ CORRECT ANSWER: B
A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals
by secondary intention. The wound is left open until it becomes filled with scar tissue. It
takes longer for a wound to heal by secondary intention; thus the chance of infection is
greater. A clean surgical incision is an example of a wound with little loss of tissue that
heals by primary intention. The skin edges are approximated or closed, and the risk for
infection is low. Partial-thickness repairs are done on partial-thickness wounds that are
shallow, involving loss of the epidermis and maybe partial loss of the dermis. These
wounds heal by regeneration because the epidermis regenerates. Tertiary intention is
seen when a wound is left open for several days, and then the wound edges are
approximated. Wound closure is delayed until the risk of infection is resolved.
5. Which nursing observation would indicate that a wound healed by secondary
intention?
, a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at the site
d. Scarring can be severe
☑️ CORRECT ANSWER: D
A wound healing by secondary intention takes longer than one healing by primary
intention. The wound is left open until it becomes filled with scar tissue. If the scarring is
severe, permanent loss of function often occurs. Wounds that heal by primary intention
heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a
lighter color than normal skin.
6. The nurse is caring for a patient who has experienced a total hysterectomy.
Which nursing observation would indicate that the patient was experiencing a
complication of wound healing?
a. The incision site has started to itch.
b. The incision site is approximated.
c. The patient has pain at the incision site.
d. The incision has a mass, bluish in color.
☑️ CORRECT ANSWER: D
A hematoma is a localized collection of blood underneath the tissues. It appears as
swelling, a change in color, sensation, or warmth or a mass that often takes on a bluish
discoloration. A hematoma near a major artery or vein is dangerous because it can put
pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be
associated with clipping of hair, dressings, or possibly the healing process. Incisions
should be approximated with edges together. After surgery, when nerves in the skin and
tissues have been traumatized by the surgical procedure, it is expected that the patient
would experience pain.
7. The nurse is working on a medical-surgical unit that has been participating in a
research project associated with pressure ulcers. The nurse recognizes that the
risk factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
☑️
d. Muscular pain. -
CORRECT ANSWER: B
Patients who are confused or disoriented or who have changing levels of consciousness
are unable to protect themselves. The patient may feel the pressure but may not
WOUND CARE, AND PRESSURE ULCER MANAGEMENT |
HIGH-YIELD QUESTIONS WITH DETAILED ANSWERS &
GUARANTEED A+ SUCCESS.
1. The nurse is caring for a patient with a large abrasion from a motorcycle
accident. The nurse recalls that if the wound is kept moist, it can resurface in
_____ day(s).
a. 4
b. 2
c. 1
d. 7
☑️ CORRECT ANSWER: A
A partial-thickness wound repair has three compartments: the inflammatory response,
epithelial proliferation and migration, and re-establishment of the epidermal layers.
Epithelial proliferation and migration start at all edges of the wound, allowing for quick
resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound
occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is
kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur,
moist or dry.
2. The nurse is caring for a patient who is experiencing a full-thickness repair.
The nurse would expect to see which of the following in this type of repair?
a. Eschar
b. Slough
c. Granulation
d. Purulent drainage
☑️ CORRECT ANSWER: C
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of
which indicates progression toward healing. Soft yellow or white tissue is characteristic
of slough—a substance that needs to be removed for the wound to heal. Black or brown
necrotic tissue is called eschar, which also needs to be removed for a wound to heal.
Purulent drainage is indicative of an infection and will need to be resolved for the wound
to heal.
3. The nurse is caring for a patient who has experienced a laparoscopic
appendectomy. The nurse recalls that this type of wound heals by
a. Tertiary intention
,b. Secondary intention
c. Partial-thickness repair
d. Primary intention
☑️ CORRECT ANSWER: D
A clean surgical incision is an example of a wound with little loss of tissue that heals
with primary intention. The skin edges are approximated or closed, and the risk for
infection is low. Partial-thickness repairs are done on partial-thickness wounds that are
shallow, involving loss of the epidermis and maybe partial loss of the dermis. These
wounds heal by regeneration because the epidermis regenerates. Tertiary intention is
seen when a wound is left open for several days, and then the wound edges are
approximated. Wound closure is delayed until the risk of infection is resolved. A wound
involving loss of tissue such as a burn or a pressure ulcer or laceration heals by
secondary intention. The wound is left open until it becomes filled with scar tissue. It
takes longer for a wound to heal by secondary intention; thus the chance of infection is
greater.
4. The nurse is caring for a patient in the burn unit. The nurse recalls that this
type of wound heals by
a. Tertiary intention
b. Secondary intention
c. Partial-thickness repair
d. Primary intention
☑️ CORRECT ANSWER: B
A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals
by secondary intention. The wound is left open until it becomes filled with scar tissue. It
takes longer for a wound to heal by secondary intention; thus the chance of infection is
greater. A clean surgical incision is an example of a wound with little loss of tissue that
heals by primary intention. The skin edges are approximated or closed, and the risk for
infection is low. Partial-thickness repairs are done on partial-thickness wounds that are
shallow, involving loss of the epidermis and maybe partial loss of the dermis. These
wounds heal by regeneration because the epidermis regenerates. Tertiary intention is
seen when a wound is left open for several days, and then the wound edges are
approximated. Wound closure is delayed until the risk of infection is resolved.
5. Which nursing observation would indicate that a wound healed by secondary
intention?
, a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at the site
d. Scarring can be severe
☑️ CORRECT ANSWER: D
A wound healing by secondary intention takes longer than one healing by primary
intention. The wound is left open until it becomes filled with scar tissue. If the scarring is
severe, permanent loss of function often occurs. Wounds that heal by primary intention
heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a
lighter color than normal skin.
6. The nurse is caring for a patient who has experienced a total hysterectomy.
Which nursing observation would indicate that the patient was experiencing a
complication of wound healing?
a. The incision site has started to itch.
b. The incision site is approximated.
c. The patient has pain at the incision site.
d. The incision has a mass, bluish in color.
☑️ CORRECT ANSWER: D
A hematoma is a localized collection of blood underneath the tissues. It appears as
swelling, a change in color, sensation, or warmth or a mass that often takes on a bluish
discoloration. A hematoma near a major artery or vein is dangerous because it can put
pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be
associated with clipping of hair, dressings, or possibly the healing process. Incisions
should be approximated with edges together. After surgery, when nerves in the skin and
tissues have been traumatized by the surgical procedure, it is expected that the patient
would experience pain.
7. The nurse is working on a medical-surgical unit that has been participating in a
research project associated with pressure ulcers. The nurse recognizes that the
risk factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
☑️
d. Muscular pain. -
CORRECT ANSWER: B
Patients who are confused or disoriented or who have changing levels of consciousness
are unable to protect themselves. The patient may feel the pressure but may not
